Using the health care physical environment to prevent ...

Using the Health Care Physical Environment to Prevent and Control Infection A Best Practice Guide to Help Health Care Organizations Create Safe, Healing Environments

A PROJECT BY: The Health Research & Educational Trust of the American Hospital Association American Society for Health Care Engineering Association for Professionals in Infection Control and Epidemiology Society of Hospital Medicine University of Michigan

ACKNOWLEDGMENTS This publication was prepared for the Centers for Disease Control and Prevention as part of Contract Number 200 – 2015 – 88275. The project was conducted by the following organizations: •

The Health Research & Educational Trust of the American Hospital Association

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American Society for Health Care Engineering (ASHE), a professional membership group of the American Hospital Association

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Association for Professionals in Infection Control and Epidemiology

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Society of Hospital Medicine

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University of Michigan

As the lead developer for this document, ASHE would like to recognize the expertise and contributions of the following: •

Project leader Linda Dickey, RN, MPH, CIC, FAPIC, Senior Director of Quality, Patient Safety & Infection Prevention, University of California Irvine Health

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Ellen Taylor, PhD, AIA, MBA, EDAC, Vice President of Research, The Center for Health Design

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Laurie Conway, RN, PhD, CIC, Infection Prevention and Control Nurse; Kingston, Frontenac, Lennox, & Addington Public Health

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Frank Myers, MA, CIC, Infection Preventionist, University of California-San Diego

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Dan Bennett, CHESP, T-CHEST, Director of Environmental Services, St. Joseph’s Hospitals, BayCare Health System

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Amy Nichols, RN, MBA, CIC, FAPIC, Director, Hospital Epidemiology and Infection Control, University of California–San Francisco Health

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Paula Wright, RN, BSN, CIC, Project Manager, Massachusetts General Hospital

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The Association for the Health Care Environment (AHE), a professional membership group of the American Hospital Association

ASHE Catalog #055196

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Table of Contents Executive Summary ................................................................................................................... 6 Quick Guides ............................................................................................................................10 Quick Guide, Chapter 1: Infection Control Risk Assessments................................................10 Quick Guide, Chapter 2: Hand Hygiene Infrastructure ...........................................................12 Quick Guide, Chapter 3: Reprocessing..................................................................................14 Quick Guide, Chapter 4: Cleaning of Environmental Surfaces ...............................................15 Quick Guide, Chapter 5: Water-Related Environmental Infection Control ..............................16 Quick Guide, Chapter 6: Flow of Patients, Personnel, Equipment and Waste........................18 CHAPTER 1: Infection Control Risk Assessments ....................................................................20 Introduction ...........................................................................................................................20 Health Care Facility Construction .......................................................................................20 Evidence-Based Design in Health Care .............................................................................21 Infection Control Risk Assessment for Health Care Facility Design ....................................21 The Business Case ............................................................................................................22 Brief Literature Review ..........................................................................................................22 A Conceptual Framework of the Role of the Built Environment and Healthcare-Associated Infections ...........................................................................................................................22 Best Practices and Recommendations ..................................................................................25 Hazards and Risks .............................................................................................................25 ICRA Development and Use ..............................................................................................26 Minimum Considerations During Design ............................................................................26 Methods to Assess Safety During Design ..........................................................................26 Minimum Considerations During Construction ...................................................................27 Opportunities for a Systems Approach ...............................................................................28 Communication .....................................................................................................................28 The Role of the Infection Preventionist...............................................................................28 The ICRA Team .................................................................................................................28 Leadership .........................................................................................................................29 Case Studies .........................................................................................................................29 Health System A: A medium-sized regional system that includes academic medical centers ..........................................................................................................................................30 Health System B: A large statewide system that includes academic medical centers ........31

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Aids for an ICRA ....................................................................................................................31 Tools .....................................................................................................................................32 CHAPTER 2: Hand Hygiene Infrastructure................................................................................43 Introduction ...........................................................................................................................43 Brief Literature Review ..........................................................................................................44 Sinks ..................................................................................................................................44 Faucets ..............................................................................................................................45 Hand Dryers and Paper Towels .........................................................................................45 General Recommendations from the Facility Guidelines Institute .......................................46 Alcohol-Based Hand Rub ...................................................................................................47 Electronic Hand Hygiene Monitoring Systems ....................................................................51 Gloves ...............................................................................................................................51 Hand Lotion .......................................................................................................................51 Construction Design Process .............................................................................................52 Best Practices and Recommendations ..................................................................................54 Sinks ..................................................................................................................................54 Faucets ..............................................................................................................................54 Hand Towels and Dryers....................................................................................................54 Product Dispensers............................................................................................................54 Alcohol-Based Hand Rub ...................................................................................................55 Electronic Hand Hygiene Monitoring Systems ....................................................................55 Construction Design Process .............................................................................................56 Case Studies .........................................................................................................................57 Facility C: Adapting to a new work flow configuration .........................................................57 Facility D: Low hand hygiene compliance in perioperative areas ........................................58 Facility E: Constant construction ........................................................................................59 Facility F: Visualizing work flow during the design of a new hospital ..................................60 Tools .....................................................................................................................................61 CHAPTER 3: Reprocessing ......................................................................................................74 Introduction ...........................................................................................................................74 Brief Literature Review ..........................................................................................................76 Best Practices and Recommendations ..................................................................................79 Sterilization and Design from the Point of Use to Reprocessing Back to the Point of Use ..79 High Level Disinfection from Dirty to Clean Storage ...........................................................83 Multipurpose Rooms ..........................................................................................................85

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Case Study ............................................................................................................................86 Hospital G: High-level disinfection areas ............................................................................86 CHAPTER 4: Cleaning and Disinfection of Environmental Surfaces .........................................89 Introduction ...........................................................................................................................89 Brief Literature Review ..........................................................................................................91 Best Practices and Recommendations ..................................................................................93 Stage 1 ..............................................................................................................................93 Stage 2 ..............................................................................................................................94 Stage 3 ..............................................................................................................................99 Stage 4 ............................................................................................................................103 Stage 5 ............................................................................................................................106 Planning for New Construction and Renovations .................................................................106 Case Studies .......................................................................................................................108 Hospital H: Multidisciplinary stakeholder coordination ......................................................108 Tools ...................................................................................................................................109 Guidelines ...........................................................................................................................109 CHAPTER 5: Water-Related Environmental Infection Control for Public and Patient Health Care Areas ......................................................................................................................................116 Introduction .........................................................................................................................116 Brief Literature Review ........................................................................................................118 Best Practices and Recommendations ................................................................................120 Water System Management .............................................................................................120 The Water Management Program Team ..........................................................................126 Case Studies .......................................................................................................................132 Academic Medical Center I: Episodic Legionnaires’ disease in existing buildings ............132 Case Study J: International point-source investigation of extracorporeal bypass equipment associated with Mycobacterium chimaera infection ..........................................................134 Case Study K: Electronically activated faucets or manually operated faucets? ................136 Case Study L: Decorative water features .........................................................................139 Tools ...................................................................................................................................140 Guidelines ...........................................................................................................................140 CHAPTER 6: Flow of Patients, Personnel, Equipment and Waste ..........................................147 Introduction .........................................................................................................................147 Importance for New Construction .....................................................................................147 Importance for Existing Facilities ......................................................................................148 How Can this Chapter Help Hospitals Improve Infection Prevention and Control? ...............149

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New Construction.............................................................................................................149 Existing Facilities .............................................................................................................149 Brief Literature Review ........................................................................................................149 Best Practices and Recommendations ................................................................................155 New Construction.............................................................................................................155 Identifying, Isolating and Containing Communicable Diseases and Transmissible Infectious Agents in the Emergency Department ..............................................................................156 Ensuring Clean Spaces and Clean Supplies Are Protected from Dust, Moisture and Other Contaminants...................................................................................................................159 Ensuring the Separation of Clean and Dirty Functions to Prevent Cross Contamination and Maintain a Sanitary Environment .....................................................................................161 Existing Facilities .............................................................................................................164 Case Studies .......................................................................................................................167 Hospital M: Aiming for all single-bed inpatient rooms and optimizing flow of patients, staff and materials ...................................................................................................................167 Case Study N: “All-hazards” disaster planning .................................................................169 Tools ...................................................................................................................................171 Texts ................................................................................................................................171 Checklists ........................................................................................................................171 CDC Guidelines ...............................................................................................................171 Miscellaneous Resources ................................................................................................172 Chapter 6 Appendix A: Summary of Recommendations for New Construction ....................173 Chapter 6 Appendix B: Summary of Recommendations for Existing Facilities .....................175

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Executive Summary Individuals enter various health care settings seeking safe, high-quality care. Patients, as well as the individuals who provide care, access health care environments in the hope that they will function as structured settings that promote positive health outcomes. Nonetheless, the transmission of infections within health care settings presents complications that can negatively affect patient and institutional well-being. Although numerous improvement efforts are ongoing, the prevalence of healthcare-associated infections (HAIs) remains a significant risk and cost within health care environments around the world. Since HAIs are identified as infections that arise specifically within health care settings, the continued prevalence of HAIs indicates a need for a better understanding of how aspects of the built environment relate to the transmission of infection, and what design, construction and operational changes can be made in the built environment to support HAI prevention. Innovations are continually being made in the fields of health care and design, making the importance of communication and cooperation between designers and health care providers increasingly more apparent. A key theme throughout this document is the importance of bringing the right disciplines together to create safe, healing environments. By exchanging perspectives during all phases of planning, construction and renovation of health care facilities, designers and health care providers can create environments that directly contribute to reduction of HAIs. By encouraging facility managers, architects and designers, construction professionals and infection preventionists to work together, particularly in early planning phases, safer health care environments will be created. This publication was created to help illustrate strategies that health care organizations can employ to optimize their buildings for improved infection prevention and control. Apart from fostering more positive health outcomes, building health care environments in a way that conscientiously addresses the issue of HAIs can also prove to be more financially sustainable. As illustrated in Figure 1, a proactive approach to safe facility design will lower costs incurred during design and construction and also influence long-term operational costs. The window to effect the most influence for lowest cost occurs in the earliest phases of design. As the design is completed and the project moves into construction, changes become increasingly expensive. Following occupancy, organizations are left with significant ongoing costs when spaces must be renovated due to missed design opportunities that may have come to light with early multidisciplinary collaboration. In addition, adverse events such as HAIs, which may not have been appropriately considered during design, may continue to occur, contributing to poor patient outcomes and unnecessary health care expenses.

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Figure 1: Moving Safety Upstream in the Health Care Facility Design Process

From placing hand sanitizers for optimal use to managing water systems to minimize pathogens, the physical environment plays an important role in infection prevention and control. This publication explores six important topics related to infection prevention and control through the physical environment: • • • • • •

Infection control risk assessment Hand hygiene infrastructure Reprocessing Cleaning of environmental surfaces Water-related environmental infection control Flow of patients, personnel, equipment and waste

Based on peer-reviewed research, this document provides background information to help readers understand how the environment contributes to infection transmission in health care settings. Interviews and case studies are shared to illustrate actual infection prevention-related successes and challenges presented by the built environment. The document also provides additional key resources specific for each topic that readers may reference for regulations, guidelines and best practices. Those looking for a brief summary of the issues and an overview of best practices can use the Quick Guides in the beginning of this publication. The remainder of this Executive Summary provides a brief overview of the six chapters included in this document. Chapter 1 discusses the infection control risk assessment (ICRA), a process by which infection risks are taken into consideration during the design and construction of a health care space. This process results in specific design, construction and commissioning recommendations and risk mitigation measures. The spread of HAIs has been associated with both health care facility design and construction activity. Ongoing cycles of facility renovation and construction present continual risks for environmental contamination and subsequent infection transmission. The ICRAs are required by jurisdictions that acknowledge or adopt the Facility Guidelines Institute

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(FGI) Guidelines for the Design and Construction of Hospital, Outpatient and Residential Facilities (three separate resources), which provide minimum standards for the design and construction of health care facilities. 1,2 The current Guidelines describe the ICRA as a proactive and integrated process for the planning, design, construction and commissioning activities to “identify and plan safe design elements, including consideration of long-range infection prevention; identify and plan for internal and external building areas and sites that will be affected during construction/renovation; identify potential risk of transmission of airborne and waterborne biological contaminants during construction and/or renovation and commissioning; and develop infection control risk mitigation recommendations (ICRMRs) to be considered.” 3 Chapter 2 illustrates how hand hygiene is essential to safe hospital care, and how the infrastructure supporting hand hygiene plays an important role in maintaining compliance. This infrastructure includes the design and placement of sinks, faucets, hand-drying facilities, and dispensers of alcohol-based hand rub. This chapter helps the reader understand how human factors play a role in hand hygiene compliance and explains how designers should consider human factors when planning hand hygiene facilities. These principles can be put into effect by: • • • • • •

Minimizing the complexity of hand hygiene. Designing features that force appropriate behaviors. Minimizing the time spent on hand hygiene. Providing cues to prompt hand hygiene. Assessing the usability of new hand hygiene systems. Testing new systems in real-life conditions.

Chapter 3 shows why reusable instruments and equipment for medical care must be reprocessed utilizing low-level disinfection, high-level disinfection or sterilization prior to use with the next patient, and why locations where these functions are performed must meet specific requirements to assure appropriate reprocessing and worker safety. Additionally, best practices are identified that demonstrate the environments in which the process is most likely to be successful. Note that Chapter 3 addresses high-level disinfection (HLD) and sterilization, while Chapter 4 goes on to address general environmental cleaning and low-level disinfection that occurs in health care. Chapter 4 discusses why cleaning and disinfecting environmental surfaces are a critical component in the prevention of HAIs and illustrates various design components that contribute to supporting or inhibiting effective environmental cleaning. For example, hard, nonporous surfaces, such as bed rails, call buttons and overbed tables form part of the environmental reservoir that are highly susceptible to microbial contamination. 4,5 Both routine and innovative new approaches may be utilized for disinfection of surfaces in patient rooms: chemical disinfection with manual cleaning; using “self-disinfecting” surfaces that are impregnated or coated with metals such as copper, silver or other germicides and no-touch technology such as ultraviolet light (UV-C) or fogging with hydrogen peroxide vapor or mist. 6 This chapter provides considerations for the built environment in view of these various methods. Health care leaders can better identify environmental process deficiencies, develop an action plan for correcting these deficiencies, implement the action plan and monitor the plan for positive outcomes. For both existing and new facilities, a multidisciplinary team including administration, nursing, environmental services, infection prevention, facility management, materials management and biomedical engineering should be formed for a successful environmental program.

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Chapter 5 provides an overview of pathogenic risks inherent in premise plumbing, that is, plumbing between entry to the building and delivery to the user. The risks are largely attributable to the development of biofilm on protected inner surfaces of plumbing systems, such as joints, dead legs, encrustations and plumbing enhancements that prevent the inner surfaces from being smooth and contiguous. 7 This chapter proposes that the design of health care facility plumbing must intentionally avoid the features that foster growth and dissemination of waterborne pathogens such as Legionella spp., pseudomonads and other gram-negative bacteria, nontuberculous mycobacteria and fungi. 8 It also discusses how patients with invasive devices (for example, central venous lines, urinary catheters, ventilators), and patients with impaired immune systems (for example, malignant hematology, solid organ transplants, extremes of age) exposed to tap water are at increased risk for infection from waterborne pathogens, and how exposure occurs through bathing, showering, drinking water or ice, and contaminated medical equipment rinsed with tap water or that holds nonsterile water. Exposure may also occur through contamination of injectable medications, solutions or antiseptics or the possibility of aerosol or droplet transmission. Ultimately, absolute prevention of waterborne pathogens is unlikely, necessitating the development of a water safety or management program that includes monitoring and a plan for mitigation when controls are out of range. Recommended practices for mitigating waterborne pathogen growth in new construction and established facilities have been published. 9,10,11,12 This chapter will incorporate recommended practices for personnel tasked with water safety in the built health care facility environment. Chapter 6 focuses on specific design strategies intended to minimize the risk of transmission of infection associated with space configuration within health care settings. These strategies include the arrangement of spaces based on intended use, the design of airflow relationships to contain contaminants or protect clean spaces, and design features intended to ensure the optimal flow of patients, personnel, materials and waste to minimize the risk of cross contamination. A portion of the chapter also specifically focuses on emergency department design to support effective triage and early isolation of potentially infectious patients, and to reduce the risk for transmission or acquisition of infection within the emergency department setting. Developing design strategies intended to prevent the transmission of infection when building or renovating health care facilities requires a fundamental understanding of how infections are spread, a knowledge of regulatory requirements and an understanding of published and new and innovative best practices for infection prevention related to the built environment. Design and construction planning requires both multidisciplinary teamwork and a commitment by leadership to assure incorporation of best practices for new and renovated spaces that optimize prevention of infection.

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Quick Guides Quick Guide, Chapter 1: Infection Control Risk Assessments Expanded information, case studies, references and other important items related to infection control risk assessments are available in Chapter 1 of this publication. The design and construction of health care facilities influence infection outcomes. To help reduce infection risks, health care organizations should perform an infection control risk assessment (ICRA) when designing, renovating or constructing a health care facility. An ICRA is required by many jurisdictions through the adoption or use of the Facility Guidelines Institute (FGI) Guidelines for the Design and Construction of Hospital, Outpatient and Residential Health Care Facilities (three separate documents). Using the ICRA process can help hospitals identify infection risks and potential solutions. An interdisciplinary ICRA team should include experts in both medical and building sciences, such as front-line caregivers from clinical departments affected by the project, facility management, quality improvement representatives, environmental safety specialists, infection preventionists, epidemiologists, architects, interior designers, engineers, human factors specialists, environmental services staff, and contractors. Other disciplines, such as risk management or lab personnel, may be helpful on an ad hoc basis. The ICRA team is responsible for conducting a health care risk assessment. A common approach to this process includes five steps: 1. 2. 3. 4. 5.

Identify the hazards. Decide who might be harmed and how. Evaluate the risks and decide on the precautions. Record findings, propose action and identify who will lead on what action. Review the assessment and update if necessary.

Design solutions may be straightforward (such as choosing plumbing fixtures that can reduce the risk of contaminated water) or they may be more nuanced (such as locating a hand hygiene sink in a space within a patient room that promotes hand hygiene compliance). Solutions to mitigate risks during construction may be more prescriptive and can be identified through tools such as an ICRA precautions matrix. An ICRA precautions matrix can help determine steps to take when conducting a construction or renovation project in a health care facility. Using the American Society for Heath Care Engineering (ASHE) ICRA precautions matrix as an example, an ICRA team would rate the type of construction (i.e., painting, sanding, duct work or new construction) and the risk of the patient groups affected (e.g., office areas, emergency rooms, operating rooms, burn unit). The precautions matrix would determine precautions needed (i.e., minimizing dust, cleaning the area after project completing, maintaining negative air pressure, using high efficiency particulate air (HEPA)-equipped air filtration units). Best practices related to ICRA processes include: • •

Ensure the ICRA team is interdisciplinary. Get infection prevention involved early in the design process. Involve the ICRA team to address minimum standards identified in several guidance

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sources, including the Centers for Disease Control (CDC) and FGI Guidelines. Use the ICRA precautions matrix to determine precautions needed during construction activity. Include construction-related requirements of the ICRA into contract documents. Since safe design relies not only on the ICRA process but also on other aspects of a health system as well (organizational policies, staff, etc.), consider different perspectives and take a systems view of safety.

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Quick Guide, Chapter 2: Hand Hygiene Infrastructure Expanded information, case studies, references and other important items related to hand hygiene infrastructure are available in Chapter 2 of this publication. Hand hygiene is essential to safe health care, and the infrastructure to support hand hygiene plays an important role in how well hand hygiene compliance is maintained. That infrastructure includes the design and placement of sinks, faucets, hand-drying facilities and dispensers of alcohol-based hand rub. Studies show that the location of sinks is more influential than the number of sinks. One study found that each additional meter between the patient’s immediate surroundings and the nearest sink decreased the likelihood of handwashing by 10 percent. However, pathogens can be spread by water splashed from sinks, so water pressure should be optimized and flow should be offset from the drain. Some studies have shown that sinks designated for handwashing, and not for patient use, improved hygiene. Valves within faucets that automatically turn on and off by themselves have been shown to contribute to pathogen transmission, even though the design intention is to reduce transmission by negating the need for users to touch the handle. These faucets may have low flow, tepid temperature and internal components (valves) that may harbor biofilm, which can contribute to microbial amplification. Paper towels are preferable to warm-air blowers for drying hands, because the towels can be used to turn off the faucet after use and the blowers may spread pathogens. However, pathogens can be spread by contaminated towel dispensers. Availability of alcohol-based hand rub dispensers has been shown to improve hand hygiene compliance. The optimal location for dispensers appears to be just outside the doorways to patient rooms. In that location, the dispenser is typically highly visible, it is on the route of the caregiver, and the action of entering the room is a trigger for the caregiver to perform hand hygiene. Dispensers immediately near or on patient beds also help compliance. The design of the dispenser also is important – a bright color and a design that differentiates the hand rub dispenser from soap dispensers improve usage. Designers should consider human factors when designing hand hygiene facilities. These principles can be put into effect in the following ways: • • • • • •

Minimize the complexity of hand hygiene. Provide design features that force appropriate behaviors. Minimize the time spent on hand hygiene. Provide cues to prompt hand hygiene. Assess the usability of new hand hygiene systems. Test new systems in real-life conditions.

Best practices related to the design of hand hygiene facilities include: • • •

Ensure handwashing sinks are separate from patient-use sinks and are not used for waste disposal. Handwashing sink placement should be near the point of care. Ensure adequate space between areas used for medical preparation, and use splash guards where appropriate. Faucets should be operable without using hands, such as with foot controls or wrist

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• • • • •

blades, and the water should angle away from the drain and flow at moderate pressure to minimize splashing. Choose paper towel dispensers that can be operated without touching, and avoid warm air dryers where noise or dispersion of bacteria would present patient risk. Install alcohol-based hand rub dispensers at patient room doors and at every bed. Evaluate the location of soap and glove dispensers at the hand hygiene sink during design. Ensure adequate space for waste containers is provided at the hand hygiene sink. During the design process, make hand hygiene processes an explicit point of concern.

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Quick Guide, Chapter 3: Reprocessing Expanded information, case studies, references and other important items related to reprocessing are available in Chapter 3 of this publication. Areas in a hospital where sterilization and high-level disinfection are performed should be designed to permit effective workflow and maintain maximum cleanliness. Important issues to consider in the design of such spaces include the type of equipment used, the proximity to areas requiring the sterilized or disinfected equipment, the ability of surfaces to withstand copious amounts of water, and the flow of equipment and personnel. The sterilization process involves five steps, the final four of which affect the design of the sterilization area. The first step is gross decontamination – the removal of visible debris – which happens frequently at the site of use and therefore doesn’t affect the design of the sterilization area. The remaining four steps are decontamination, packaging for sterilization, sterilization, and storage, each of which affects space design. The type of sterilizing equipment used affects design. For example, a table-top sterilizer does not require much infrastructure. Steam sterilizers require a certain quality of steam, separate access for maintenance and careful placement of air ducts. Hydrogen peroxide plasma sterilizers operate at lower temperatures than steam sterilizers, and thus demand less of the infrastructure. Ethylene oxide sterilizers demand more infrastructure because of safety issues and processing requirements unique to this modality. The requirements for space used for high-level disinfection may differ from those of the space used for sterilization. Endoscopes and vaginal probes are examples of two items commonly reprocessed in high-level disinfection areas. Many hospitals use automated endoscope reprocessors, which have specific water pressure needs. The chemicals used in high-level disinfection must be disposed of properly, which may necessitate more infrastructure. In both sterilization areas and high-level disinfection areas, the lighting in the sink areas must be bright to allow for effective removal of all visible debris. Staff in these areas must wear personal protective equipment, which can take up space and affect air temperature requirements. In addition, the spaces should be designed to minimize staff interruption and distraction. The materials used in these areas must withstand copious amounts of water: wood or pressboard should not be used, and walls must not allow for fungal growth if saturated with water. Humidity and ventilation of these spaces also must be closely controlled. Best practices in designing sterilization and high-level disinfection areas include: • • • •

Flow through the space must be unidirectional from dirty to clean. Pipes, conduit or ductwork located above work areas should be enclosed to prevent dust accumulation, and ceilings should be made of materials that do not shed particulates. Sterilizers should be located in restricted areas to prevent accidental removal of unsterilized equipment. Hand-washing sinks should be readily available so staff can wash after handling items yet to be processed and before handling processed items.

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Quick Guide, Chapter 4: Cleaning of Environmental Surfaces Expanded information, case studies, references and other important items related to the cleaning of environmental surfaces are available in Chapter 4 of this publication. Effectively cleaning and disinfecting surfaces in health care settings is essential to the prevention of infections. Pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and others (e.g., spores of Clostridium difficile, Acinetobacter baumannii, etc.) can survive for a long time on surfaces and infect patients, and studies have shown that traditional chemical cleaning methods do not always adequately remove the pathogens. New technologies have entered the market and show promise in reducing these pathogens, including improved chemical disinfectants, antimicrobial surfaces that may reduce the numbers of organisms on a surface over time, and “no touch” automated disinfection systems. It is a best practice to form a multi-disciplinary team that establishes policies and procedures regarding room cleanliness and disinfection. The team should include staff from administration, infection prevention and control, nursing, environmental services, and facility management. The team should develop a five-stage plan: 1. Determine which chemicals will be used to clean and disinfect surfaces, paying particular attention to the specific needs of the health care organization and various departments. Once the chemicals are chosen, establish usage guidelines. 2. Define policies and procedures, including what the cleaning tasks are, which department is responsible for each, how often the task should be completed, and which products will be used for each task. Pay particular attention to identification of “orphan items” that may not have been clearly designated to anyone for cleaning. Checklists and daily assignment sheets are useful tools for maintaining adherence to protocols. 3. Train environmental service staff and any other personnel designated to clean surfaces. New hires should be trained, and existing staff should have ongoing training. Staff should take part in yearly competency testing. 4. Effectiveness of cleaning and disinfecting should be regularly monitored, such as with direct observation, fluorescent marker systems or adenosine triphosphate (ATP) ATP bioluminescence assays. Timely feedback should be provided to staff, including the results of the cleaning and disinfecting monitoring results. 5. The multidisciplinary team should conduct an analysis and evaluate new technology for environmental cleaning and assess the need and application of these new technologies in their hospital setting.

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Quick Guide, Chapter 5: Water-Related Environmental Infection Control Expanded information, case studies, references and other important items related to waterrelated environmental infection control are available in Chapter 5 of this publication. Plumbing in a health care facility can house pathogens. Taking steps to minimize pathogen growth is important. Pseudomonas grow in stagnant water found within the plumbing system, such as in joints, dead legs, encrustations and plumbing enhancements. The pathogens are closely associated with biofilms, which provide protection and food, and they are typically dispersed when biofilm reaches certain development phase or during sloughing events such as when the water system is disrupted, such as during construction or during high-demand periods. Since completely eliminating these pathogens is unlikely even in new construction, it is important to develop a water safety or management program that iteratively monitors water at predetermined locations and addresses out of range control metrics when noted. A multidisciplinary water management team should be developed in all health care facilities. This team, which should be given the authority to implement water decisions, has a number of important tasks. These include mapping the water system; analyzing hazards; developing mitigation strategies; establishing metrics; enacting policies that identify hazards; conducting surveillance for disease caused by waterborne pathogens; and developing a strategy for replacement of current higher-risk premise plumbing problem areas. Each team member has specific areas of responsibility. A risk assessment is an important step in water system management. The risk assessment should identify potential problems with the domestic the water source, inlets, flow, stagnation, heat transference, faucets/showers/drains and other areas. Another important part of the risk assessment is to develop a plan to deal with water disruptions, both planned and unplanned, since such disruptions can lead to the dispersal of pathogens. Regular monitoring of water disinfection strategies by the water source is key to understanding incoming water risks. Water quality reports should be routinely reviewed, and, if utilized, supplemental disinfection methods adjusted accordingly. Adjunct disinfection strategies for health care facilities to consider include hypochlorite, chlorine, chlorine dioxide, copper-silver ionization, hyper-chlorination filtration, ultraviolet light and thermal control. All have advantages and disadvantages. Best practices regarding waterborne pathogen management include: • • • • •

Create and empower a multidisciplinary water management team. Among other purposes, this team socializes the concept of a water safety program. Perform a risk assessment for all water systems and water-containing equipment. Include water within equipment, stagnant water plumbing during construction, and rarely used locations, such as eye-wash stations and emergency showers. Be involved in renovation and construction to provide safe plumbing expertise. Avoid in-hospital decorative water features (water walls, reflecting pools, fountains). Be aware of waterborne pathogens and the diseases they may potentially cause, and maintain surveillance for trends. Some of these diseases include pneumonia, bloodstream infections, surgical site infections, meningitis, gastroenteritis and urinary tract infections.

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• •

Develop and execute an action plan to mitigate risks and address outbreaks when they occur. Monitor key metrics established by the water safety team to demonstrate that the water safety program is working. Key metrics may include 1) process control measures, such as chlorine levels or measurements of temperature control, 2) the burden of pathogens in humans (patients and health care professionals) and/or 3) the burden of pathogens in water as epidemiologically indicated.

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Quick Guide, Chapter 6: Flow of Patients, Personnel, Equipment and Waste Expanded information, case studies, references and other important items related to the flow of patients, personnel, equipment, and waste are available in Chapter 6 of this publication. The risk of infection transmission in a hospital can be reduced by a number of strategies, including proper configuration of space, airflow design that minimizes the spread of pathogens, and design features that ensure the optimal flow of people and material to minimize cross contamination. Separating patients who are actively ill with an infectious disease from other patients, either through isolation or barriers, is an important component of infection prevention. Consequently, designing spaces such airborne infection isolation rooms is important. Another way to limit the spread of infection is the development of “respiratory hygiene/cough etiquette,” protocols which encourages patients and visitors with a cough or fever to cover their cough with tissues and to perform hand hygiene. This is especially important in emergency departments, where patients and their families often wait together for long periods of time and infectious patients may not be recognized immediately. Providing barriers (such as plexiglass dividers) for worker safety at triage entry points and provision of space for masks, tissues and hand sanitizer are examples of design considerations to support infection prevention. Designing “flow” in in a health care setting also can reduce the spread of infection. For example, emergency departments may be designed with “pods” and zones and may include procedures that allow for triage “flex” to accommodate changes in patient volume. Creative use of barriers can help when crowding may present a challenge. Design should also consider the movement of environmental waste in the hospital, so that it can be removed and disposed of without the risk of pathogen spread. Among the best practices in hospital design for reducing the spread of infection are: • • • • •

• • •

A multidisciplinary team should consider all aspects of infection prevention when the functional program of a new health care facility is being developed. Just as with new construction, infection prevention staff should be part of the planning team for updating and renovating existing facilities. Reflexively recreating existing work flows or spaces should be avoided. Incorporate infection prevention staff into plans for all areas of the hospital, including disaster and surge capacity planning. Consider designing an AII isolation room/area that enables unidirectional flow of health care professionals (HCP) entering/exiting for patients with highly infectious diseases. Use Human Factors Engineering (HFE) methods to analyze tasks as they are performed in existing spaces. Ask “what design features contribute to the lack of compliance”. Work with HCP to design spaces/systems that support efficient workflows for HCP to access clean supplies while still protecting clean and sterile supplies from contamination. Remember that the separation of clean and dirty functions to limit cross contamination is fundamental to infection prevention. In areas designed to control airborne contaminants, ensure the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and relative humidity. Provide space outside of clinical areas for removal of supplies from external shipping boxes.

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• •

Ensure adequate storage on patient units for reusable patient care equipment and a location where these items may be cleaned. Explore new technology or simple containment approaches for the disposal of human waste.

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CHAPTER 1: Infection Control Risk Assessments

Ellen Taylor, PhD, AIA, MBA, EDAC, Vice President of Research, The Center for Health Design Introduction Health Care Facility Construction A continuous cycle of health care facility renovation and replacement is influenced by both infrastructure conditions and external factors (for example, economic conditions and the regulatory environment). The first building boom began in 1946 when the Hill-Burton program provided federal funding for the capital development of hospitals and health care facilities in the United States. 13 Wing reported that by 1974 when the legislation was replaced with the National Health Planning and Resources Development Act, $5 billion in grants and loans had fueled $14.5 billion in construction and modernization projects affecting more than 496,000 hospital and long-term care facility beds (about 40 percent of U.S. acute care hospital beds). Facilities age, and while a hospital physical plant lifespan is estimated to be 30 to 70 years, 14,15 many facilities become obsolete before the end of their effective physical lives. 16 The American Hospital Association (AHA) defines the useful life of a building as 40 years. 17 A 2007 analysis found that health care sector construction spending grew faster than the rest of the economy and the value of hospital construction permits per capita was at the highest level since 1969. 18 These data are consistent with the AHA estimated 40-year lifespan of a health care facility. While the economic recession of 2008 resulted in a precipitous drop in spending, construction spending through the end of 2016 is trending upward again as shown in Figure 2. 19 A recent survey found that 25 percent of an organization’s capital budget was allocated for new construction, 24 percent for renovation and 15 percent for infrastructure improvements, with renovation accounting for nearly 77 percent of the projects underway or planned in the next three years. 20

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Figure 2: Total Health Care Construction Spending

The aging and obsolescence of U.S. health care facilities generate a constant need for repair, remediation work (cabling, room additions) and replacement; in turn, ongoing risks of environmental contamination continue, affecting air and water quality. 21 Evidence-Based Design in Health Care The constructed health care facility is delivered following a design process, and the design of health care facilities has also evolved over the decades. For example, using varied information sources to aid in decision making has always been part of design, but the introduction of more rigorous research sources launched the growth of a process of evidence-based design. The Center for Health Design defined evidence-based design as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” 22 Two comprehensive reviews of the literature provided an understanding of the body of research suggesting a relationship between facility design and outcomes, such as safety. 23,24 As one factor influencing safety, facility design may impact patient safety directly or indirectly as a latent condition leading to adverse events. 25,26,27,28 A healthcare-associated infection (HAI) is just one safety-related outcome related to the built environment with potential transmission through multiple routes: contact, air and water (See the literature review section later in this chapter). Infection Control Risk Assessment for Health Care Facility Design Owners are responsible for conducting the infection control risk assessment (ICRA) using an interdisciplinary expert panel. The use of risk assessments for infection control during design and construction have been evolving for the past several decades. A formal “Infection Control Risk Assessment” was introduced in the 1996-1997 edition of the Guidelines for Design and Construction of Hospitals although earlier editions required construction and renovation assessments related to specific risks. The goal of the assessment was to “describe how an organization determines the risk for transmission of various infectious pathogens.” 29 A multidisciplinary committee was to coordinate the infection control needs of the individual

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organization with the appropriate requirements for the isolation of infectious disease. Commonly, this early context resulted in the ICRA becoming a part of prevention planning solely for construction activity; however, infection prevention considerations during design of the project were not systematically integrated. The acronym “ICRA” appeared in the 2001 edition where the process was mandated as a continuous activity throughout programming, planning, design and construction of projects. 30 The ICRA in the Guidelines envisioned a long-range involvement of infection control/epidemiology leadership. 31 The Business Case The costs of infections have been estimated 32,33 and the cost-benefit of infection control programs evaluated. 34,35 However, business cases rarely recognize any contribution of the built environment. Part of the challenge in incorporating the built environment in the business case is that the complex causes of HAIs are multifactorial in nature. 36,37,38 The complexity makes it difficult to determine the exact role of a single specific facility design feature in infection prevention 39 in the context of a necessary “bundle.” 40 The cost-benefit of the built environment has most often been represented through theoretical papers based on the literature and experiences of individual facilities. These can act as a narrative for discussion in health care settings, 41,42,43 but these types of narratives should be reviewed in the context of any stated assumptions (for example, cost avoidance, interpretation of research) that might warrant adjustment. 44 Brief Literature Review Transmission of pathogens in a hospital is complex, with multiple transmission pathways, hosts, reservoirs and sources. Pathogens can enter the hospital through infected or colonized humans, including patients, or come from external sources. 45 An early narrative review describing the role of the environment in infection control provides an overview of the health care design pertinent to the control of puerperal fever, aspergillosis, tuberculosis and Legionellosis through considerations such as ventilation (for example, heating, ventilation, and air conditioning systems), isolation (for example, patient room occupancy), water disinfection (for example, metal ionization), fixture and surface selection and availability of hand hygiene locations. 46 A more recent systematic literature review contracted through the Agency for Healthcare Research and Quality resulted in a special supplement addressing the role of facility design in the acquisition and prevention of healthcare-associated infections. 47 A Conceptual Framework of the Role of the Built Environment and Healthcare-Associated Infections Zimring et al. 48 established a conceptual framework for the environment’s role in infection control using a “chain of transmission” model that can be viewed as a map of the predicted route of pathogens including a distinction between direct and indirect transmission (Figure 3).

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Figure 3: The chain of transmission adapted from Zimring et al., 2013

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Zimring’s article was published in a special issue with other papers focused on opportunities in the environment for the prevention of HAIs transmitted by contact, air and water with survival time on inanimate surfaces ranging from hours to minutes 50,51,52 The following sections (contact, airborne, waterborne) provide a high-level summary of the study findings. Contact

Many organisms can survive on surfaces for days, weeks or months. However, the presence of a pathogen may lead to colonization but not infection, and an infection may develop long after acquisition. 53 According to Steinberg et al., most HAIs are caused by organisms that are carried by the patient or transmitted from one person to another, making the exact role of environmental surfaces in causing healthcare-associated infections unclear. However, the authors cite a number of studies that suggest the chain of transmission between environmental contamination and HAIs through direct or indirect contact. To summarize the authors’ findings, 54 strategies to prevent the transmission of pathogens include:

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• • • • • •

Adherence to and monitoring of cleaning protocols. Room disinfection technologies to supplement manual cleaning such as ultraviolet germicidal irradiation or hydrogen peroxide/hydrogen peroxide vapor. Surfaces that resist contamination and are easily cleaned such as hard floor surfaces in patient care areas. Materials that have antimicrobial properties such as copper alloys used for high touch surfaces (for example, door handles, bed rails). Physical barriers such as single patient rooms. Hand hygiene infrastructure that promotes hand hygiene compliance through clearly visible sinks and gels in convenient and standardized locations.

Additionally, appropriate use of personal protective equipment (PPE) is an essential strategy to prevent contact spread of infection. PPE convenience/accessibility and visibility within the workflow are important considerations during design. 55 Airborne

Infection from airborne pathogens is a result of a complex interaction of the pathogen, the individual and the inanimate environment. Airborne transmission occurs when infectious particles, small and light enough to float for distances on air currents, are inhaled. Mitigating risk is important in protecting health care personnel, patients and visitors from being exposed to patients with infectious diseases transmitted via air. 56 Primary interventions to interrupt transmission of small airborne particles include ventilation, filtration and isolation/pressurization. 57 •

•

•

Ventilation: Design considerations include the airflow of heating, ventilation and air conditioning systems (that is, turbulent airflow for upward displacement, vertical downflow systems, horizontal cross-flow distribution systems and unidirectional laminar air flow systems). Filtration: Filtration of ventilated air can reduce the number of airborne pathogens, and this is often achieved through HEPA (high efficiency particulate air) filtration in specific areas of the hospital or through filters treated with antimicrobial agents. Filtration is used as a result of air quality associated with the use of both outside (fresh) and recirculated air. Isolation/pressurization: The use of airborne infection isolation rooms controls airflow from unclean to clean through the use of positive or negative pressurization and/or anterooms. Negative pressure isolation rooms (higher pressure to lower pressure airflow gradient for airborne infection isolation rooms) are used for airborne infection isolation rooms (e.g., patients with highly transmittable airborne pathogens such as tuberculosis). In contrast, positive pressure rooms (lower pressure to higher pressure airflow gradient) keep contaminated air away in protective environment isolation rooms (e.g., immunocompromised patients).

Waterborne

According to Denham and colleagues, 58 pathogens from water sources account for only a small fraction of HAIs. However, these may be under-recognized and under-reported. Denham et al. 59 report that other waterborne pathogens are opportunistic (for example, Pseudomonas aeruginosa, nontuberculous mycobacteria, etc), often living harmlessly in or on humans but causing infection under certain conditions. They cite that other bacteria types that persist in the environment (for example, Acinetobacter spp.) may be low virulence organisms but are frequently a cause of intensive care unit-related infections. Similar to other transmission modes,

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evidence clearly identifying the environment's role in the chain of infection is limited. 60 The authors point out that while public water in the United States is treated, even low concentrations of waterborne pathogens can be dangerous for immunocompromised patients. In summary, Denham et al. 61 conclude that interrupting the chain of transmission of waterborne pathogens includes three primary approaches (proactive or reactive) that include: • •

•

Disinfection of water through chlorination, hyper-chlorination, superheat-and-flush, copper-silver ionization or ultraviolet germicidal irradiation. Selection of appropriate design elements to minimize the potential for contamination such as faucets (including no-touch electronic faucets), sinks, and aerators; point-of-use filters (where costs should be balanced with the estimated risk); carefully considered decorative fountains (the most recent Facility Guidelines Institute (FGI) Guidelines precludes the use of open fountain systems inside health care facilities, although sealed systems can be used). Safe plumbing practices to eliminate dead legs and maintain optimal water temperature/ pressure.

Adding to the complexity of the relationship between infection and the health care facility design is the fact that specific patients may be at more risk: patients such as neonates 62; pediatric patients 63; burn patients 64; hematology patients. 65,66 those who are immunocompromised and others. 67 As a result, specific spaces have different considerations requiring a comprehensive understanding of the epidemiology of infections and the potential role of facility design to contribute to solutions. 68,69,70,71,72,73,74 Best Practices and Recommendations An ICRA is necessary in both design and construction, but the approaches to identifying risks and solutions are different. Design solutions may be straightforward, for example, to mitigate a direct risk (fixture and equipment selections to prevent contaminated air and water) or they may be more nuanced (for example, the location of a hand hygiene sink to promote compliance). Solutions to mitigate the risks during construction are more prescriptive and can be identified through tools such as an ICRA precautions matrix. Several guidelines provide requirements and best practice recommendations for the ICRA process; these are outlined below. However, the ICRA practice can also be advanced through explicit thinking about safety science and complexity in health care and how these concepts can be supported by health care facility design. Hazards and Risks A hazard can be defined as a source of danger, 75 for example, non-circulating hot water improperly maintained or water temperature maintained in ranges that allow bacterial growth. 76 Risk is associated with the probability (chance) of an outcome, 77,78 for example, the chance that a pathogen in the water results in a patient becoming infected. Risk is subjective and is relative to an individual’s or organization’s perspective, therefore certain risks may be both acceptable and necessary. 79,80 The purpose of risk assessment is to inform decisions that involve risk, costs and benefits. 81 Risk is often discussed either numerically or descriptively with respect to the severity of harm (consequence) and the likelihood of the occurrence of that harm. 82,83 In one case study, a facility design team modified a more traditional and complicated numeric approach into a simpler descriptive system of low, medium or high. 84 A common challenge is that many risk management processes identify and assess problems without systematically identifying risk control solutions. 85

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ICRA Development and Use Standard approaches in safety science mitigate risk through properties of prevention, protection and facilitation. 86 Mitigating risk is often addressed through elimination, design controls or administrative procedures. 87 Relatively few studies report about tools that support proactively designing for safety and mitigating design-related risk. 88,89,90 These studies do not focus on infection control in detail but describe the development tools for safe health care facility design. A limited number of studies cover the development and use of an ICRA process or specific ICRA tools. Most reports are part of conference presentations and proceedings 91,92,93,94,95 and most focus on construction. Kennedy and colleagues’ 1996 study 96 is one of the first appearing references to present the use of a risk matrix for barriers during constructions. This led to what is now commonly used as an ICRA precautions matrix (see the tools section at the end of this chapter). Moore and Huber 97 describe improved ICRA compliance following the assignment of a construction trained infection preventionist to construction activities, and Kidd et al. 98 outline compliance following the implementation of a contractor training program. Johnson and Lenz 99 retrospectively identify the underlying conditions leading to errors during construction using a human factors framework to understand the complex interactions of the system. Dickey and Taylor 100 presented the most recent requirements for a proactive multidisciplinary safety risk assessment in the 2014 FGI Guidelines. 101,102 The safety risk assessment requirements are largely based on the framework established by the ICRA, and infection control is one of multiple safety components to be considered during design and construction. Minimum Considerations During Design This interdisciplinary team should address minimum standards identified in several guidance sources. 103,104,105 These include the number, location and type of airborne infection isolation and protective environment rooms; special heating, ventilation, and air-conditioning needs (for example, in surgical areas, airborne infection isolation (negative pressure) and protective environment (positive pressure) rooms, labs, pharmacies and areas with hazardous agents using local exhaust systems); water and plumbing systems; and the selection of materials for surfaces and furnishings. The team should also consider the design implications for potential natural and man-made disasters. 106 Methods to Assess Safety During Design Numerous methods can be used to assess safety as part of the design process. A report on designing for patient safety cites the potential for several methods already in use in other areas of health care based on usability, relevance, feasibility and generalizability. 107,108 These methods include link analysis, root cause analysis, failure mode and effects analysis, simulation, work sampling, balanced scorecard and process analysis. These processes evaluate design options in the context of other aspects of the system and are not a prescriptive list of design solutions. Several methods (failure mode and effects analysis, simulations and link analysis) were most highly rated to be of use across design phases and support decision making at varying levels of design detail. Morrill 109 used a failure mode and effects analysis where participants identified key areas of risk, bringing clarity to the desired conditions and necessary next steps and engaging in prompt decision making about facility design solutions.

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A risk assessment in health care facility design can be conducted as a proactive approach to safety. A common approach to conducting a health care risk assessment includes five steps 110: 1. 2. 3. 4. 5.

Identify the hazards. Decide who might be harmed and how. Evaluate the risks and decide on the precautions and risk mitigation strategies. Record findings, propose action and identify who will lead on what action or strategy. Review the assessment and update periodically if necessary.

The same steps are used in health care facility design and construction. Minimum Considerations During Construction Risks associated with construction include dust and debris compromising the environment, airborne microbes journeying via air currents to infect other susceptible hosts, an unbalanced ventilation system affecting air quality, water stagnation and contamination, accumulated and multiple waste reservoirs and ineffective dustproof barriers, and managing the transportation of waste and contaminated workers, among others. 111 Two reviews of the literature 112,113 outlined the characteristics of outbreaks and infections associated with construction, renovation and demolition. Given the extent of known conditions, construction-related requirements of the ICRA must be included into the contract documents and implemented during construction. 114 According to the FGI and The Association for Professionals in Infection Control and Epidemiology (APIC), 115,116, 145 the minimum considerations for construction include the disruption of essential services and the impact on those occupying the building; identification of specific hazards and protection levels for each designated area; plans for locating patients according to their infection vulnerability; the impact of movement of debris, traffic flow, spill cleanup, and testing and certification of installed systems; assessment of both internal and external construction activities and identification of known hazard locations. An ICRA precautions matrix is often used to guide this process. 117,118,119 The matrix is recommended during the design process to assist the multidisciplinary team to identify the patient population at risk and the preventive measures to be initiated. The matrix describes the levels of construction activity and four risk groups (lowest to highest risk), and provides identification of the risk groups that may be affected by their proximity or exposure to the construction zone. As part of the infection control risk mitigation recommendations, specific methods to reduce the potential for the transmission of airborne and waterborne biological contaminants are documented in writing. The FGI Guidelines 120,121 include the following considerations as a minimum standard: 1. Patient placement and relocation plans. 2. Protection from airborne contaminants (barriers and other protective measures to protect adjacent areas and patients), demolition and emergencies—planned and unplanned utility outages and evacuation. 3. Phasing (or temporary provisions) for construction or modification of heating, ventilation and air conditioning and water supply systems. 4. Training for staff, visitors and construction personnel. 5. Construction worker flows including construction worker routes (for example, elevator use for personnel and materials); movement of debris, traffic flow, cleanup; and

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provisions for bathroom and food facility use. 6. Installation of clean materials that have not been damaged by water. Opportunities for a Systems Approach Safety requires a systems approach that takes into account the interactions of the complex system of health care that includes the organization, the people and the environment in which care takes place. According to Storr et al., 122 a systems approach using human factors and ergonomics can be used to move infection prevention into thinking for everyday work flow in health care as compared to viewing infection prevention activities as additional workload. A recent study on hand hygiene used a human factors framework to understand the interactions of the systems, including how the built environment might influence outcomes. 123 Design for hand hygiene has also used a human factors ergonomics framework to ensure usability 124 and help capture understanding of mental models. 125 (See also Chapter 2.) Others suggest the complexity of health care requires embedding a macro-ergonomic approach at an organizational level to effectively use human factors in an infection prevention approach. 126 While conducting an ICRA during design and construction is often required as part of a health care facility project, a safe environment should not be designed in a silo. A traditional approach to safety (Safety-I) assumes that adverse events occur because of identifiable failures or malfunctions of technology, procedure, personnel and the organizations in which they work in a stable environment of known, stable controllable conditions. 127 Organizations reactively identify contributing factors to an adverse event and establish procedures to prevent a reoccurrence. Newer views of safety (Safety-II) supplement a Safety-I approach and attempt to develop proactive ways to support things the many things that “go right,” helping people adapt to variation, disruption and degradation of expected conditions. 128,129,130 In creating built environment solutions that are part of the ICRA, this means incorporating other aspects of the system (for example, organizational policies and procedures, staff and patients, different perspectives and expertise) as part of the solution to optimize both the health and well-being of the facility occupants and overall system performance. Communication The Role of the Infection Preventionist In the past, infection control considerations were minimized during design and construction, if not forgotten, which led to the possibility of costly (preventable) mistakes 131 and an increase in ongoing life-cycle costs. 132 As infection control and prevention (IPC) has been evolving and today, infection preventionists (IPs) play an important role in the development and ongoing maintenance of infection prevention and control programs. 133,134,135,136 Still, many may consider the role of an infection preventionist as operational, so leadership and communication must promote the proactive involvement of infection preventionists during design. An infection preventionist should be part of the interdisciplinary team during facility design, and the infection preventionist must routinely address infection control factors throughout the project and assist administration in understanding the rationale for the floor plan, equipment and furnishings required to support sound infection control practices. 137 The ICRA Team To adequately understand the issues and potential solutions in both design and construction, an interdisciplinary ICRA team is necessary. This team can identify key design features to enhance safety of patients, personnel and visitors through diverse perspectives to ensure the

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environment supports complex interactions of human factors and behavior. 138 Several documents offer suggestions for participants of an ICRA team that include experts in both medical and building sciences such as front-line caregivers from clinical departments affected by the project, facilities management, performance and/or quality improvement representatives, safety specialists, infection preventionists, epidemiologists, architects, interior designers, and/or engineers, human factors specialists, environmental services staff, laboratory personnel, contractors and risk management personnel. 139,140,141 Leadership The leadership team should establish a vision to measure and target outcome improvements and use building design and construction to advance cultural transformation; redesign care processes; and mitigate the risk of patient and staff harm, reduce stress and improve the bottom line. 142 Leadership of health care organizations should have an awareness of the role of the built environment to promote safety and insist on interdisciplinary teams of experts (internal and external) that can combine their knowledge and experience to optimize facility design solutions. However, while health care personnel often generate risk control plans, with the assumption that a good understanding of risk will lead to good risk control, the same personnel are generally not trained in the principles of safety science. 143 This warrants additional guidance and structure to aid in the process for infection preventionists and the rest of the team. A systematic process of risk assessment for health care facility design can advance participation and collaboration and foster an evidence-based process for decision making. Case Studies Infection preventionists are increasingly included in the design and construction of health care facilities as part of the infection control risk assessment process. Interviews were conducted with two experienced IPs to understand process, barriers and opportunities in well-established programs. Common to both organizations is a less organized process for considering infection control during design, a higher level of structure and standardization for the construction mitigation phase, and years of participation in the process to create organizational awareness and “buy-in.” The standardization for construction helps set expectations and accountability (and would benefit design, as well). Each organization enters construction-related information into an online system for both new construction and renovations and the timing of the process is dependent on the scope—larger projects being entered well in advance of construction. As shown in Figure 4, System A uses a hierarchical process of alert and sign-off, whereas in System B, the online construction mitigation is a collaborative effort. (An important perception in System A that may exist in other organizations is related to the term “ICRA,” which is perceived to apply solely to construction mitigation as compared to the broader definition that encompasses the full design cycle.) Each organization has multiple IPs, but each structures the role of the IP in a different way.

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Figure 4: Dual approaches to including IPs during the design ICRA

Health System A: A medium-sized regional system that includes academic medical centers The ICRA process is managed by the facility project management team. Three project managers working for a contracted real estate management firm are responsible for facility project management associated with new construction and/or renovation. In large scale projects, the IP is brought in by the system’s contracted project managers once a project is initiated. The project manager is also responsible for including the IP at appropriate intervals within the project. Design questions related to infection control are not standardized or structured by any kind of tool but are discussed in face-to-face meetings and are not explicitly considered relative to risk levels. In some cases, it may feel like the design ideas come from thin air. If the type of space is familiar to the IP, the project review may be done remotely. For project types that are less familiar, it is more important to be present, either on-site looking at the conditions or at a meeting where drawings are being discussed. As referenced above, the ICRA for construction mitigation is addressed through a structured online format that is also used for construction permitting. While there are five IPs in the system, a single IP is assigned to all design and construction projects, allowing for consistency and continuity, especially in lessons learned from project to project and in the relationships that are developed. As a result, the IP is fully embedded in the process. The IP has the opportunity to engage at different levels depending on the project, keeping end users aware of infection prevention-related decisions and issues that may arise during the project and chooses whether to attend all or selective meetings, determines how much IP-related education might be needed for an unfamiliar team on smaller projects and provides feedback during room mockups.

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Health System B: A large statewide system that includes academic medical centers Most projects are managed by an internal capital project management office, but some smaller projects (e.g., maintenance of plumbing) may be led by facility management. Increasingly, everyone is aware to contact the IP for ICRA-related input. The IP department relies on project management to notify the department about projects that involve infection prevention. During design, the IP is invited to provide input at different stages and to look at design issues specific to infection prevention in an iterative manner. There is not a structure or tool that is used in a systematic way so the process is somewhat “free flowing.” The architects are generally responsible for completing meeting minutes and providing the subsequent design direction to their team. The level of involvement is related to the project scope, but the IP department would like to be included on projects from the earliest phases, even programming, to ensure items are not overlooked. Managed by the project management office of capital planning, the ICRA for construction risk mitigation is hard-wired and completed in a stepwise manner online during a preconstruction risk assessment meeting. Participants include the contractor and subject matter experts, as needed, and an algorithm is used to review conditions such as adjacencies, risks associated with the scope of the project, and control of air and water. This is viewed together on screen and becomes part of the construction documents. The department head has sent everyone to the American Society for Health Care Engineering (ASHE) training for a basic understanding for IP role in design and construction. The infection prevention department is divided by unit (e.g., med-surg, ICU). Each IP on the team is familiar with the stakeholders for their assigned area (nurse managers, physicians and others who should have been involved in planning and design). That same IP follows the project through to the discussion for construction mitigation. The IP team meets on a weekly basis about all projects (performance improvement and construction) and can ask questions of each other or their peers within the system or colleagues in other organizations throughout the country. The ICRA is needed throughout the project lifecycle to address safety in general through an interdisciplinary team that can break down silos with input that supports all stakeholders. A significant benefit of early use of the ICRA for programming and design is to ensure that requirements are appropriately established such that change orders do not incur additional costs. Following construction, commissioning needs to occur to ensure proper functioning of systems, for example, ensuring airflow and pressure are correct, standing water is not present, and so forth. Aids for an ICRA The audience for the ICRA is really the C-suite. The CFO and CEO need to understand the financial and safety implications that result when an IP is not brought in early. Even though you have to slow down to move fast, it’s time and effort well-spent. Many are completely unware of the requirement for the safety risk assessment. There is a lot vying for the attention of those on the C-Suite—often threats and opportunities at a national level—and if ICRA/safety risk assessment (SRA) examples or case studies could reach into reputable journals read by the Csuite, or in meetings they are likely to attend, this would aid in strengthening the ICRA process from a quality, safety and financial perspective. Influential papers could also be shared with professional organizations such as APIC or The Society for Healthcare Epidemiology of

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America (SHEA) for member dissemination. A secondary route is to approach ICRA and safety from a regulatory standpoint, through the Centers for Medicare & Medicaid Services (CMS) or the Joint Commission. Tools APIC offers ICRA resources through their continually updated APIC text, a subscription-based service (http://text.apic.org/). The organization also supports infection preventionists with resources such as the 2015 release of the Infection Prevention Manual for Construction & Renovation. 144 APIC offers training for ICRA activities as part of their consulting services and the ECRI Institute offers an online training program (www.ecri.org/components/Pages/Infection_Control_Risk_Assessment.aspx). Several tools and resources are available to guide the development of solutions to facilitate safety. To proactively consider infection control during design, the Center for Health Design has developed a Safety Risk Assessment toolkit for the design of health care facilities. This toolkit supports the requirements in the FGI Guidelines and is available at no charge in an online format (www.healthdesign.org/sra). In the Safety Risk Assessment toolkit, infection control is one of six components of safety to be considered during design. The Safety Risk Assessment content was developed with grant funding through a research-based consensus process 145 and tested through both hypothetical scenarios and real-world conditions. 146 The Center for Health Design offers training and workshops in the use of the tool as a participatory process during design and an online webinar provides an overview of the tool’s development and use (https://www.healthdesign.org/insights-solutions/safety-risk-assessment-20). Free short tutorial videos are also included in the online version of the Safety Risk Assessment toolkit. The Center for Health Design also developed a framework that outlines the safety issues to be considered in the design of various residential and long-term care settings. 147 The resulting matrix serves as a broad evaluation framework for key design areas (for example, noise, light levels, design of outdoor spaces) contributing to resident safety. Healthcare-associated infections are one of the referenced outcomes. Another tool that might be used during health care facility design is a process tool developed to optimize the development of risk control solutions. 148,149 The Generating Options for Active Risk Control (GO-ARC) tool is not specific to infection control but outlines a structured brainstorming technique with prompts used to elicit risk control options (http://activeriskcontrol.com/tools-andtemplates/). Additional design resources can be found at Premier Safety Institute’s building design links page (www.premiersafetyinstitute.org/safety-topics-az/building-design/buildingdesign-links/). With respect to construction, numerous organizations post similar versions of the ICRA precautions matrix originally conceived by Kennedy et al. 150 One version can be found at the Premier safety Institute (www.premiersafetyinstitute.org/safety-topics-az/buildingdesign/infection-control-risk-assessment-icra/) as well as at ASHE’s website (www.ashe.org/resources/tools/pdfs/assessment_icra.pdf). An easy-to-read description of the process was written by Streifel and Hendrickson 151 and is posted by Industrial Air Solutions (www.industrialairsolutions.com/contamination-control/hospital-air-purifiers-pdf/HPACConstruction-maintenance-health%20care-facilities.pdf).

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Morrill, P. W. (2013). Risk assessment as standard work in design. HERD: Health Environments Research & Design Journal, 7(1), 114–123. 110 National Patient Safety Agency—National Reporting and Learning Service. (2007). Healthcare risk assessment made easy (Guidance No. 0555) (pp. 1–16). London: NHS National Patient Safety Agency (NPSA). Retrieved from www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=60138 111 Bartley, J., & Bjerke, N. B. (2001). Infection control considerations in critical care unit design and construction: A systematic risk assessment. Critical Care Nursing Quarterly, 24(3), 43–58. 112 Bartley, J. (2000). APIC state-of-the-art report: The role of infection control during construction in health care facilities. American Journal of Infection Control, 28(2), 156– 69. 113 Kanamori, H., Rutala, W. A., Sickbert-Bennett, E. E., & Weber, D. J. (2015). Review of fungal outbreaks and infection prevention in healthcare settings during construction and renovation. Clinical Infectious Diseases, 61(3), 433–444. https://doi.org/10.1093/cid/civ297. 114 Bartley, J., & Bjerke, N. B. (2001). Infection control considerations in critical care unit design and construction: A systematic risk assessment. Critical Care Nursing Quarterly, 24(3), 43–58. 115 Facility Guidelines Institute. (2014). 2014 guidelines for design and construction of hospitals and outpatient facilities. Chicago, IL: American Society for Healthcare Engineering. 116 Facility Guidelines Institute. (2014). 2014 guidelines for residential health, care, and support facilities. Chicago, IL: American Society for Healthcare Engineering. 117 American Society for Healthcare Engineering. (2017). Tools | Planning, Design, and Construction [AHA personal membership group]. Retrieved February 5, 2017, from http://www.ashe.org/resources/tools.shtml 118 Bartley, J., & Olmsted, R. (2007). Construction and Renovation. Arlington, VA: APIC. 119 Division of Nosocomial and Occupational Infections, Health Canada. (2001). Constructionrelated nosocomial infections in patients in health care facilities [Canada Communicable Diseases Report No. HP3-1-27-S2]. Retrieved from Health Canada http://publications.gc.ca/collections/collection_2016/aspc-phac/HP3-1-27-S2-eng.pdf 120 Facility Guidelines Institute. (2014). 2014 guidelines for design and construction of hospitals and outpatient facilities. Chicago, IL: American Society for Healthcare Engineering. 121 Facility Guidelines Institute. (2014). 2014 guidelines for residential health, care, and support facilities. Chicago, IL: American Society for Healthcare Engineering. 122 Storr, J., Wigglesworth, N., & Kilpatrick, C. (2013). Integrating human factors with infection prevention and control. Retrieved from http://www.health.org.uk/publication/integratinghuman-factors-infection-prevention-and-control. 123 Yanke, E., Zellmer, C., Van Hoof, S., Moriarty, H., Carayon, P., & Safdar, N. (2015). Understanding the current state of infection prevention to prevent Clostridium difficile infection: A human factors and systems engineering approach. American Journal of Infection Control, 43(3), 241–247. https://doi.org/10.1016/j.ajic.2014.11.026. 124 Suresh, G., & Cahill, J. (2007). How “user friendly” is the hospital for practicing hand hygiene? An ergonomic evaluation. Joint Commission Journal on Quality and Patient Safety, 33(3), 171–179. 125 Sax, H., & Clack, L. (2015). Mental models: A basic concept for human factors design in infection prevention. Journal of Hospital Infection, 89(4), 335–339. https://doi.org/10.1016/j.jhin.2014.12.008. 126 Clack, L., Kuster, S. P., Giger, H., Giuliani, F., & Sax, H. (2014). Low-hanging fruit for human

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factors design in infection prevention—Still too high to reach? American Journal of Infection Control, 42(6), 679–681. https://doi.org/10.1016/j.ajic.2014.03.002 127 Braithwaite, J., Wears, R. L., & Hollnagel, E. (2015). Resilient health care: Turning patient safety on its head. International Journal for Quality in Health Care, 27(5), 418–420. https://doi.org/10.1093/intqhc/mzv063 128 Hollnagel, E., & Woods, D. D. (2006). Epilogue: Resilience engineering precepts. In E. Hollnagel, D. D. Woods, & N. Leveson (Eds.), Resilience engineering–Concepts and precepts (pp. 347–358). Aldershot, UK: Ashgate Publishing, Ltd. Retrieved from http://www.researchgate.net/profile/David_Woods11/publication/265074845_Epilogue_R esilience_Engineering_Precepts/links/546b62c70cf2397f7831bdfc.pdf 129 Woods, D. D., & Hollnagel, E. (2006). Prologue: Resilience engineering concepts. In E. Hollnagel, D. D. Woods, & N. Leveson (Eds.), Resilience engineering. Concepts and precepts (pp. 1–16). Aldershot, UK: Ashgate Publishing, Ltd. Retrieved from http://erikhollnagel.com/onewebmedia/Prologue.pdf 130 Braithwaite, J., Wears, R. L., & Hollnagel, E. (2015). Resilient health care: Turning patient safety on its head. International Journal for Quality in Health Care, 27(5), 418–420. https://doi.org/10.1093/intqhc/mzv063. 131 Bartley, J., & Bjerke, N. B. (2001). Infection control considerations in critical care unit design and construction: A systematic risk assessment. Critical Care Nursing Quarterly, 24(3), 43–58. 132 Taylor, E., Hignett, S., & Joseph, A. (2014). The environment of safe care: Considering building design as one facet of safety. Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare, 3(1), 123–127. https://doi.org/10.1177/2327857914031020 133 Cook, E., Marchaim, D., & Kaye, K. S. (2011). Building a successful infection prevention program: Key components, processes, and economics. Infectious Disease Clinics of North America, 25(1), 1–19. https://doi.org/10.1016/j.idc.2010.11.007 134 Haley, R. W., Culver, D. H., White, J. W., Morgan, W. M., Emori, T. G., Munn, V. P., & Hooton, T. M. (1985). The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. American Journal of Epidemiology, 121(2), 182–205. 135 Rebmann, T. (2009). APIC state-of-the-art report: The role of the infection preventionist in emergency management. American Journal of Infection Control, 37(4), 271–281. https://doi.org/10.1016/j.ajic.2008.12.002. 136 Spencer, M. P. (2013). Role of the corporate infection preventionist consultant in a multihospital system. American Journal of Infection Control, 41(6), S20. https://doi.org/10.1016/j.ajic.2013.03.041 137 Bartley, J., & Bjerke, N. B. (2001). Infection control considerations in critical care unit design and construction: A systematic risk assessment. Critical Care Nursing Quarterly, 24(3), 43–58. 138 Bartley, J., & Streifel, A. J. (2010). Design of the environment of care for safety of patients and personnel: Does form follow function or vice versa in the intensive care unit? Critical Care Medicine, 38(8 Supplement), S388–S398. 139 Facility Guidelines Institute. (2014). 2014 guidelines for design and construction of hospitals and outpatient facilities. Chicago, IL: American Society for Healthcare Engineering. 140 Centers for Disease Control and Prevention (CDC). (2003). Guidelines for Environmental Infection Control in Health-Care Facilities. Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf 141 Memarzadeh, F. (2011). The environment of care and healthcare-associated infections: An

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engineering perspective (ASHE Monograph). Retrieved from ASHE/FGI http://www.ashe.org/management_monographs/pdfs/mg2011memarzadeh.pdf 142 Zimring, C., Augenbroe, G. L., Malone, E. B., & Sadler, B. L. (2008). Implementing healthcare excellence: The vital role of the CEO in evidence-based design. HERD: Health Environments Research & Design Journal, 1(3), 7–21. 143 Card, A. J., Ward, J., & Clarkson, P. J. (2012). Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis. Journal of Healthcare Risk Management, 31(3), 6–12. https://doi.org/10.1002/jhrm.20090. 144 Vogel, R. (Ed.). (2015). Infection Prevention Manual for Construction & Renovation. Arlington, VA: APIC. 145 Taylor, E., Joseph, A., Quan, X., & Nanda, U. (2014). Designing a tool to support patient safety: Using research to inform a proactive approach to healthcare facility design. In Advances in Ergonomics In Design, Usability & Special Populations: Part III (Vol. 18, pp. 7889–7899). Krakow, Poland: AHFE International. 146 Taylor, E., Quan, X., & Joseph, A. (2015). Testing a tool to support safety in healthcare facility design. Procedia Manufacturing, 3, 136–143. https://doi.org/10.1016/j.promfg.2015.07.118 147 Joseph, A., & Quan, X. (2012). Resident safety risk assessment (pp. 1–30). Retrieved from The Center for Health Design https://www.healthdesign.org/chd/knowledgerepository/resident-safety-risk-assessment 148 Card, A. J., Ward, J., & Clarkson, P. J. (2012). Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis. Journal of Healthcare Risk Management, 31(3), 6–12. https://doi.org/10.1002/jhrm.20090 149 Card, A. J. (2014). The Active Risk Control (ARC) toolkit: A new approach to designing risk control interventions. Journal of Healthcare Risk Management, 33(4), 5–14. https://doi.org/10.1002/jhrm.21137 150 Kennedy, V., Barnard, B., & Hackett, B. (1996). Use of a risk matrix to determine level of barrier protection during construction activities. In ABSTRACTS Papers accepted for presentation at APIC ‘96: Twenty-third Annual Educational Conference and International Conference, 24, 111. Retrieved from American Journal of Infection Control http://www.ajicjournal.org/article/S0196-6553(96)90004-8/pdf 151 Streifel, A. J., & Hendrickson, C. (2002, February). Assessment of health risks related to construction. HPAC Engineering, 27–32. http://www.industrialairsolutions.com/contamination-control/hospital-air-purifierspdf/HPAC-Construction-maintenance-health%20care-facilities.pdf

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CHAPTER 2: Hand Hygiene Infrastructure

Laurie Conway, RN, PhD, CIC, Infection Prevention and Control Nurse; Kingston, Frontenac, Lennox, & Addington Public Health Introduction Infrastructure that supports good hand hygiene is critical to patient safety. The design and placement of sinks, faucets and dispensers for alcohol-based hand rub influences patients’ risk for HAIs directly and indirectly. Directly, the built environment itself can be a vector for infections. The design of handwashing sinks and their placement relative to patients and patient care materials warrant careful consideration so that waterborne pathogens are not transferred from the environment to patients. 152,153,154,155 Aerosols and splashes from contaminated handwashing sinks have been implicated as the source of outbreaks that resulted in patient infections and deaths. 156,157,158 Indirectly, the built environment can facilitate or impede proper hand hygiene behavior by health care personnel, thereby affecting transmission of microbes and infection. Improvements in hand hygiene have been associated with reduced rates of infections in hospitalized and long-term care patients. 159160161 Thus, a poor physical design that impedes hand hygiene will increase patients’ risk of infection. Deficiencies in the structural layout of hand hygiene resources include poor visibility, poor access, placement at an undesirable height, lack of redundancy, lack of standardization, and wide spatial separation of supplies that are used sequentially. 162 Any of these ergonomic flaws can act as a barrier to hand hygiene. Expert hand hygiene guidelines affirm the importance of the built environment for promoting hand hygiene. 163,164,165 Alcohol-based hand rub is generally preferred for most hand hygiene opportunities, because it requires less time to use, causes less skin irritation and is more effective in reducing the bacterial count on hands than soap and water. 166 However, washing hands is recommended in some circumstances such as when hands are visibly soiled and during outbreaks of norovirus or Clostridium difficile infection. 167,168,169 Thus, infrastructure for both hand sanitizing and hand washing will be considered in this chapter. The purpose of this chapter is to help health care facilities prevent and control infections by providing excellent hand hygiene infrastructure in new construction and existing facilities. A review of current literature addressing hand hygiene infrastructure is provided, followed by recommendations for the design and placement of sinks, faucets, hand towels and dryers and alcohol-based hand rub dispensers. Four case studies are provided to illustrate the practical application of recommendations. Also provided are tools that can be used to assess existing hand hygiene infrastructure, prioritize areas for improvement and select the most appropriate equipment and products.

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Brief Literature Review Most studies of hand hygiene infrastructure are observational or quasi-experimental in design. Thus, the evidence for action is of moderate or low quality. Here, we summarize the evidence from primary research, as well recommendations from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), Society for Healthcare Epidemiology of America (SHEA), the Facility Guidelines Institute (FGI) and others where appropriate. 170,171,172,173,174 With a few exceptions, we focus on studies published after the 2002 CDC guidelines. Sinks Number of Sinks

Evidence suggests that increasing the number of handwashing sinks does not of itself increase hand hygiene compliance. In one study, hand hygiene compliance by nurses in an intensive care unit with a sink-to-bed ratio of 1:1 was 25 percent higher than in another intensive care unit with a sink-to-bed ratio of 1:4. 175 However, the study sampled only 160 hand hygiene opportunities, and did not control for possible confounders such as sink location or staffing levels. Three other studies, also conducted prior to the widespread use of alcohol-based hand rub, did not show any improvement in hand hygiene rates when the number of handwashing sinks was increased. 176,177,178 The negative results were similar across settings and unit types. Location of Sinks

The proximity of sinks to the patient may influence hand hygiene performance more than the absolute number. A study of hand hygiene during care of patients with C. difficile infection in one hospital found that hand washing compliance was independently associated with the distance of the sink from the patient. In their setting of one sink per eleven beds, and distances of 1.2 to 37.8 meters (4 to 124 feet) between the patient’s immediate surroundings and the sink, each additional meter decreased the likelihood of hand washing by 10 percent. 179 However, the benefits of having sinks in close proximity to patients must be balanced with the risk of aerosols and splashes reaching the patients directly. During an outbreak of multi-drug resistant Pseudomonas aeruginosa in an adult intensive care unit, investigators found that water that flowed forcefully from the faucets and directly into the drains of handwashing sinks splashed onto adjacent surfaces and onto patients at a distance of more than 1 meter away. 180 The outbreak ended after sinks were redesigned so that water flow was offset from the drain and water pressure was reduced. Another study in a neonatal intensive care unit found that air samples taken half a meter from sinks with water running showed that a majority were positive for P. aeruginosa. 181 The impact of sink contamination and aerosolization of pathogens was demonstrated in a study in which removal of sinks from patient rooms in the ICU was associated with reduced colonization of patients with Gram negative bacilli. 182 Designated Handwashing Sinks

Some literature suggests that designating certain sinks for hand washing may reduce contamination of the hands of health care personnel. A study published in 1996 established that health care personnel’s hands can become contaminated when washing at a patient sink. 183 In a pediatric unit that housed patients with cystic fibrosis, 21 of 24 sinks were contaminated with P. aeruginosa or Burkholderia cepacia. The researchers instructed 17 staff members to disinfect their hands with alcohol-based hand rub and then wash their hands at one of the contaminated sinks for 30 seconds and dry with paper towels. By glove juice method, five of the 17 health care personnel were positive for the same strain as the sink.22 These results led to a

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recommendation by the Public Health Agency of Canada to avoid using patient sinks for hand washing whenever possible. 184 However, dedicated handwashing sinks may be similarly contaminated, especially if the sinks have been inappropriately used for other purposes. During an outbreak of Elizabethkingia meningoseptica, investigators discovered that nurses were using handwashing sinks for disposal of patient waste and for rinsing used patient care items. 185 Isolates recovered from the handwashing sinks were indistinguishable from patient isolates. Similarly, during an outbreak of Shigella sonnei in a microbiology lab, investigators discovered that concentrated Shigella suspension had been disposed of in a handwashing sink rather than a processing sink. 186 This break in protocol, combined with the fact that use of paper towels for turning off faucet handles had a protective effect for the technologists, led the researchers to conclude that the contaminated sink had been the source of the outbreak. Further study is needed to determine whether use of dedicated handwashing sinks results in less contamination of health care personnel’s hands than use of patient sinks. Faucets Numerous studies have examined electronic sensor-regulated faucets, which conserve water and should reduce hand contamination by negating the need to touch faucet handles. The studies suggest, however, that rather than reducing pathogen transmission, sensor-regulated faucets may contribute to it. Most studies report that counts of Pseudomonas and Legionella species are significantly higher in water from sensor-regulated faucets than from conventional faucets. 187,188,189,190,191 Contamination can persist despite remediation with chlorine dioxide.3,25,27 Design features typical of sensor-regulated faucets that have been implicated include low flow, tepid temperature, fittings made of polyvinylchloride rather than copper and contaminated aerators. 192,193,194 Investigation of an outbreak of P. aeruginosa infections in neonatal units in Northern Ireland found the mean count of P. aeruginosa in aerators of conventional faucets was two percent of the mean count in aerators of sensor-regulated faucets. 195 No difference was observed in P. aeruginosa counts for any other faucet components. Complex plastic aerators had significantly higher counts of P. aeruginosa than simple designs. However, complex aerators were only found on sensor-regulated faucets, making it impossible to determine whether it was the design of the aerator or another attribute of the sensor-regulated faucet that resulted in higher contamination with P. aeruginosa. 196 The Canadian Standards Association mandates against aerators on faucets for hand hygiene sinks in health care facilities. 197 Hand Dryers and Paper Towels Some evidence suggests that for drying hands, paper towels may be preferable to air dryers. 198 The CDC recommends that after washing, hands should be dried thoroughly with a disposable paper towel. Drying removes residual moisture that facilitates transfer of microbes to and from hands, and friction helps remove microbes. The paper towel should be used to turn off the faucet. A recommendation is made against multi-use cloth towels from a rotary dispenser. There is no comment on air driers. 199 Since that publication, warm air hand driers have been investigated further, in regards to their ability to remove microbes from hands and tendency to disperse microbes into the environment. In general, no difference in the removal of bacteria has been found after drying by paper towels compared to air dryers. 200,201,202 However, bacterial counts are higher if hands are rubbed under a warm air dryer than if they are held still. 203,204

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More than one study has identified heavier contamination of the immediate environment when hands are dried using a warm air dryer (blade-type) compared to paper towels. 205,206 In a laboratory experiment, when jet air dryers were used, bacterial counts were 27 times higher than when paper towels were used, and 4.5 times higher than when air dryers were used. 207 The significance of these environmental bacterial counts to infection control is not known. A systematic review of the relative efficacy of paper towels and air dryers concluded that paper towels are superior to electric air dryers from a hygienic viewpoint, and thus should be used in hospitals and clinics. 208 Studies have shown that pathogens can be transferred from contaminated paper towel dispensers to clean hands. In a laboratory setting, researchers loaded standard folded paper towels into generic stainless-steel front-loading paper towel dispensers, then used Serratia marcescens and Micrococcus luteus to contaminate the exit slots. Subjects were instructed to pull out paper towels by reaching into the dispenser exits. Results showed that between four and 16 percent of organisms contaminating the dispenser exits were transferred to the volunteers’ hands. 209 Contamination of the exit slots of paper towel dispensers has been confirmed in the clinical setting. 210 In eight wards in four hospitals in the United Kingdom, researchers found that 19 percent of dispensers were in excess of the clean benchmark value of 2.5 cfu/cm2 for aerobic colony counts and staphylococci, and more than 80 percent exceeded desirable adenosine triphosphate (ATP) levels (>500 relative light units). 211 Although faucet handles and soap dispensers were more heavily contaminated than paper towel holders, the paper towels may present a more important risk for transmission since they are accessed after hands are washed. Studies have also documented that lever-type dispensers can be cumbersome to use. In one long-term care facility, researchers found that each pump of the lever delivered a scant 5.4 inches of paper towel. Paper dispensed prior to hand washing was splashed with water from the faucet. 212 General Recommendations from the Facility Guidelines Institute The FGI makes specific recommendations for the design and installation of sinks, faucets, hand dryers and alcohol-based hand rub dispensers in hospitals, long-term care facilities and outpatient facilities. 213,214 Readers are referred to the source documents for information about specialty facilities, support areas and surgical scrub stations. The following is a brief summary of the essential recommendations for general patient areas in hospitals: Number and Location of Hand Hygiene Stations

1. Provide a handwashing station in the patient room in addition to the one in the toilet. a. A handwashing station includes a faucet that can be operated without using hands (e.g. wrist blades or sensor activated), soap and a means of drying hands. 2. The station should be located near the room entrance, outside cubicle curtains and with visible, unobstructed access. a. In open-plan multi-patient areas, provide at least one handwashing station for every four beds, spaced so that the two farthest beds are about equidistant from the hand wash station. b. In intensive care units provide one handwashing station for every three beds. 3. Provide alcohol-based hand rub dispensers in addition to hand wash stations. 4. Use the infection control risk assessment to determine the number and placement of handwashing stations and alcohol-based hand rub dispensers.

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Design of Sinks and Faucets

1. Sinks should be designed to minimize splashing onto adjacent areas. a. Basins should be of adequate size and depth to minimize splashing (nominal size not less than 144 square inches; minimum dimension of 9 inches in width or length). b. Faucets should discharge water so that it is angled away from the drain. c. Water pressure should not be forceful enough to cause splashing. 2. Sinks should be made of porcelain, stainless steel or solid-surface materials. 3. Countertops should be made of porcelain, stainless steel, solid-surface materials or sealed plastic laminate over marine-grade plywood. a. Under-mounted sinks are discouraged. b. Casework should prevent storage beneath the sink. 4. Sinks should fit tightly against the wall or countertop and be sealed to prevent water leaks. 5. Mirrors should not be mounted above handwashing stations in areas where hair combing should be discouraged. 6. Faucets should discharge water at least 10 inches from the bottom of the basin. 7. Faucets should be operable without using hands. a. Wrist blade handles should be at least four inches long. b. Sensor-regulated faucets should meet user need for temperature and length of time the water flows. c. Sensor-regulated faucets should be operable during loss of normal power.

Hand Dryers

1. Hand drying devices should not require hands to contact the dispenser. 2. Paper towels should be enclosed and dispensed in single units. 3. While hot air dryers are permitted, paper towels are preferable.

Alcohol-Based Hand Rub Although at least one study of the introduction of alcohol-based hand rub recorded no change in hand hygiene compliance, 215 many subsequent studies have documented an improvement in hand hygiene compliance. In one large hospital that had one to three sinks in every patient room, hand hygiene compliance increased from 48 percent to 66 percent over three years after alcohol-based hand rub dispensers were mounted on beds and individual pocket dispensers were distributed. 216 However, it is impossible to assess the influence of other interventions introduced at the same time. 217 Similar increases in hand hygiene frequency have been documented after alcohol-based hand rub dispensers were installed in long-term care facilities, 218 academic medical centers, 219 and children’s hospitals. 220 The effects were consistent across different professional groups. Based on this evidence, the CDC, WHO and SHEA strongly recommend providing health care personnel with a readily accessible alcoholbased hand rub product. 221,222,223 A recent systematic review examined the efficacy of providing alcohol-based hand rub to patients for facilitating patient hand hygiene and/or reducing infections. 224 All ten included studies showed improvements in hand hygiene and/or lower infection rates, but all were at moderate to high risk of bias. Most of the interventions were multi-modal and included assistance from staff to use the alcohol-based hand rub, diminishing the relative importance of simple provision of alcohol-based hand rub. As the authors note, bedside dispensers would be inappropriate for many patient populations, including those who are confused or at risk for selfharm. 225

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Number of Alcohol-Based Hand Rub Dispensers

Some evidence points to a positive correlation between the number of alcohol-based hand rub dispensers and hand hygiene compliance. In a medical intensive care unit, hand hygiene compliance after patient care increased from 22 percent to 41 percent when alcohol-based hand rub dispensers were introduced in a ratio of one dispenser per four beds, and further increased to 48 percent when dispensers were added at every bed. 226 A survey of 309 hospitals in Europe found that in intensive care units and medical and surgical wards where alcohol-based hand rub was available at more than 75 percent of points of care, alcohol-based hand rub consumption was higher than in areas with less availability. 227 Because alcohol-based hand rub is flammable, fire regulations restrict the number alcoholbased hand rub dispensers that may be installed within a given area. To meet the Centers for Medicare & Medicaid Services Conditions of Participation, hospitals, long-term and intermediate care facilities, ambulatory surgery centers, inpatient hospices and other types of health care facilities are required to adhere to the 2012 editions of the Nation Fire Protection Association’s NFPA 101: Life Safety Code®, and NFPA 99: Health Care Facilities Code. 228 The Life Safety Code dictates the upper limits for the size of dispensers, number of dispensers allowed within a single smoke compartment, distance between dispensers and separation between dispensers and sources of electricity. 229 The Joint Commission also endorses NFPA 101 in their document Acceptable Practices of Using Alcohol-Based Hand Rub. 230 The regulations reflect an abundance of caution; fires involving alcohol-based hand rub are rare. A 2003 survey of hospitals in all 50 United States found there had been no fires involving alcohol-based hand rub in 1,430 hospital years of use. 231 Similar findings were reported in a survey of 788 German hospitals. 232 A majority of the hospitals had wall dispensers mounted in patient rooms (70 percent), corridors (80 percent), and operating rooms (69 percent). Seven incidents had occurred in a combined 25,038 hospital years using alcohol-based hand rub. The incidents were precipitated by personnel lighting cigarettes or candles with hands still moist with alcohol-based hand rub (n=4), or by vandalism (n=2) or suicide attempt (n=1). 233 Location of Alcohol-Based Hand Rub Dispensers

The location of alcohol-based hand rub dispensers may influence hand hygiene compliance more than the absolute number of dispensers. The CDC strongly recommends that alcoholbased hand rub be available at the entrance to the patient’s room or at the bedside, in other convenient locations, and in individual pocket-sized containers for health care personnel. 234 They comment that alcohol-based hand rub dispensers should not be placed adjacent to sinks, lest they be confused with soap dispensers. 235Researchers have compared the effect of relocating alcohol-based hand rub dispensers with the effect of increasing their number, and found location was more influential. 236,237 The optimal location for dispensers is just outside the doorways to patient rooms. 238,239,240,241 The ideal in-room location is less certain, but attaching a dispenser to every patient bed may be optimal if the dispensers are not obstructed by curtains or equipment. 242,243,244 Researchers conducted work flow observations, interviews, focus groups, surveys, automated counts of dispenser usage and field tests to identify processes and environments that were supportive of hand hygiene. 245 Study settings included a family medicine clinic, an inpatient rehabilitation unit, an intensive care unit and an emergency department. Results showed that across health care settings, the optimal location for alcohol-based hand rub was just outside of a patient’s room within arm’s reach of the door. Although no consistent optimal location was observed inside patient rooms, the foot of each patient bed was one location identified by health care

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personnel. 246 Similarly, a review of hand hygiene literature concluded that the two most important locations for alcohol-based hand rub dispensers were by the entrance of patient rooms and within arm’s reach of where care takes place. 247 In one adult general care unit, locating alcohol-based hand rub dispensers at the foot of patient beds and strategically throughout the hallways offered optimal usability, provided standardization and met regulatory requirements. 248 Locating dispensers in the hallway at the entrance to patient rooms has strong underlying rationale. An ethnographic study of medical ward design found that entering and exiting private rooms served as a reminder to perform hand hygiene. 249 In addition, the room entry location meets other requirements for usability; namely, it is on the clinicians’ work route, unobstructed by equipment or other clinicians, in the line of sight, and similar from room to room. 250 Mounting literature supports the notion that visibility of alcohol-based hand rub dispensers is a key factor in improving hand hygiene. In a community hospital, researchers found that locating dispensers close to the room entrance and easily visible on entry significantly and independently influenced hand hygiene compliance. 251 Another study, which assigned 150 doctors and nurses to examine standardized patients, reported that average hand hygiene compliance before patient contact was 37 percent when dispensers were located just inside the doorway but were not visible upon entering the room. 252Hand hygiene compliance improved to 53 percent when flickering lights were added to the dispenser, and to 60 percent when the dispenser was relocated so that it was in the clinician’s line of sight on room entry. When both visual cues were combined, compliance improved to 67 percent. 253 Two studies suggest that locating alcohol-based hand rub dispensers in direct line of site of visitors may increase visitor hand hygiene frequency in hospital lobbies. 254,255 Brightly colored dispensers may also improve hand hygiene compliance, either by drawing attention, or by indicating the contents of the dispenser. In a medical intensive care unit where hand hygiene compliance was already high, replacing alcohol-based hand rub dispensers with dispensers colored signal red resulted in a further six percent increase in compliance. 256 Dispensers for soap, lotion and alcohol-based hand rub that are similar in size, shape and color and use the same actuation method can be a barrier to hand hygiene. 257 Discipline-specific focus groups conducted with physicians, nurses, allied health personnel and housekeepers suggested that colored labels on dispensers would improve hand hygiene practice. 258 Colors thought to be most intuitive were pink for soap, yellow for lotion and blue for alcohol-based hand rub. SHEA comments that it is important for health care personnel to be able to distinguish between alcohol-based hand rub for surgical hand preparation and alcohol-based hand rub for routine use. 259 Inconsistent dispenser height (as high as 57 inches) was reported to be problematic in three studies. 260,261,262 The optimal height for dispensers is thought to be between 33 and 44 inches (85 to 110 cm) above the finished floor. 263 Dispensers at the Point of Care

The optimal dispenser location for supporting hand hygiene at room entry and exit has been studied more thoroughly than at the point of care. This may be attributable to the Joint Commission’s focus on hand hygiene compliance at room entry and exit, rather than at all five moments proposed by the WHO, and on the difficulties associated with monitoring hand hygiene compliance inside patient rooms at the point of care. 264Providing hand hygiene infrastructure at the immediate point of care (that is, within arm’s reach of the patient) is especially important because contacts during aseptic procedures and after body fluid exposure may present the highest risks for transmission of microbes between health care personnel and

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patients. Although hand hygiene opportunities at the point of care occur less frequently than on room entry or exit, compliance is especially poor at the point of care. 265 Options for positioning alcohol-based hand rub dispensers at the point of care include wall-mounting dispensers, hanging dispensers in brackets (for example, on wheelchairs or IV poles), putting dispensers on horizontal surfaces (for example, overbed tables, window sills or procedure carts) and providing small bottles that health care personnel can carry in their pockets. 266 A systematic review of the impact of point of care alcohol-based hand rub dispensers on hand hygiene compliance identified three studies, all of which showed increases in hand hygiene when dispensers were located near the patient’s bed. 267 An industry-funded survey completed by 350 doctors and nurses in the United States and Canada found that alcohol-based hand rub was readily available at less than 90 percent of hospitals. 268 However, a majority of respondents agreed that their hand hygiene performance would improve if alcohol-based hand rub was located closer to the patient. When asked where alcohol-based hand rub should be positioned, the first choice of participants was a wall-mounted dispenser within three feet of the patient (77 percent) and the second choice was attached to the foot of the bed (42 percent). Locations infrequently chosen by respondents included inside the room entrance, on the IV pole, on the nightstand and in the pockets of health care personnel. 269 Among anesthesia providers, after accounting for gender, level of training, glove use and distance between the anesthesia machine and wall-mounted alcohol-based hand rub dispenser, researchers found that hand hygiene was performed more frequently when an alcohol-based hand rub dispenser was available on the anesthesia machine compared to when it was only available in a wall-mounted dispenser, which was located on average 7.2 feet away. 270 When considering locating alcohol-based hand rub dispensers at the point of care, some populations warrant special consideration. SHEA notes that “cognitively impaired, behavioral health, or substance abuse patients may be injured by ingestion of alcohol-based hand rub. A point-of-care risk assessment can help guide placement of dispensers or decision to use nontoxic hand hygiene products.” 271 Dispenser Design

Hands-free alcohol-based hand rub dispensers may be preferred by health care personnel over manual dispensers. 272 A drip tray can be integrated into the design of alcohol-based hand rub dispensers. An automated door handle dispenser, which releases alcohol-based hand rub from a cartridge directly into the user’s hand was pilot tested in a radiology department. 273 Directly observed hand hygiene compliance increased from 25 percent to 77 percent in the room with the dispenser handle, but did not change in two control rooms. The results may have been affected by novelty effects. 274 Poorly functioning or empty alcohol-based hand rub dispensers can be a barrier to compliance. The CDC recommends that before purchasing decisions are made, dispenser systems should be evaluated to ensure they function well. 275 Also, hand hygiene behavior should be monitored carefully when a new system is introduced, to exclude any negative effects of the new devices or products. When alcohol-based hand rub dispenser systems were novel technology, Kohan and colleagues installed wall-mounted dispensers throughout their hospital. Sixteen months later, inspection revealed that only 77 percent of the dispensers were functioning (2 percent were broken, nine percent were obstructed, and the reservoir was empty or absent in 12 percent). 276 Of the working dispensers, 35 percent required more than one pump to deliver any product. Reports also tell of malfunctioning dispensers spraying health care personnel or creating a fall risk due to slippery floors. 277

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In a survey of 350 doctors and nurses in active clinical practice, empty dispensers were among the top three reasons for not performing hand hygiene. 278 Four strategies have been suggested for keeping dispensers filled: (1) purchase dispensers that have flags to cue environmental services staff that they are empty, (2) purchase dispensers that have transparent windows to clearly show product levels, (3) affix a label to each dispenser displaying the phone number to call for refill, and (4) establish an “adopt-a-dispenser” program to encourage individual environmental services staff (EVS) to keep their dispenser full. 279 In a field test of the flag strategy, one team of researchers found that the flags were poorly visible and rarely used. 280 The CDC strongly states that partially empty product dispensers should not be “topped up” with more soap. 281 Electronic Hand Hygiene Monitoring Systems Monitoring and feedback of hand hygiene performance is widely recommended, and is required by The Joint Commission. 282,283,284 However, direct observation of hand hygiene is laborintensive and only a small fraction of total hand hygiene opportunities are sampled. Also, health care personnel who know they are being observed may change their behavior during the observation and revert to usual behavior when the observer leaves. For this reason SHEA recommends using more than one method to measure hand hygiene compliance. 285 Electronic hand hygiene monitoring systems are available in a range of configurations, from simple electronic counters embedded in dispensers to complex systems that issue real-time feedback to health care personnel. 286 Table-top and personal dispensers can be monitored in addition to wall-mounted dispensers. Electronic hand hygiene monitoring systems measure large numbers of hand hygiene opportunities and are unobtrusive. Some systems are capable of providing real-time feedback. The evidence that electronic monitoring systems improve health care personnel hand hygiene performance is not yet convincing. A systematic review of the literature identified seven studies that evaluated the efficacy of electronic hand hygiene monitoring systems for improving hand hygiene. 287 Although four studies showed increases in raw compliance scores of 34 to 75 percent with the introduction of electronic monitoring, three other studies demonstrated minimal to no difference. Overall study quality was poor and none of the studies used an objective measure of hand hygiene compliance that was independent of the system being tested. 288 Facilities that are considering installing an electronic hand hygiene monitoring system may encounter several challenges, including disruption of physical infrastructure and clinician work flow, problems delivering the data directly to health care personnel and the concerns of personnel about the accuracy of the system and the potential for punitive use of the data. 289 Gloves SHEA recommends that glove use should be considered in any discussion of hand hygiene. 290 Glove use is especially important when caring for patients with norovirus or C. difficile infection. Although more research is needed to determine whether hand hygiene is necessary before donning non-sterile gloves, it makes sense to provide gloves close to other hand hygiene supplies. The society suggests that glove boxes be designed so that the act of dispensing gloves from the box does not contaminate the remaining gloves in the box. 291 Hand Lotion CDC strongly recommends that heath care personnel be provided with hand lotions or creams to minimize the occurrence of dermatitis associated with hand hygiene. 292 SHEA notes that irritant contact dermatitis is the most frequently occurring adverse reaction to hand hygiene

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products. They recommend providing lotion in non-refillable containers, and encouraging its use. 293 Construction Design Process Some literature is available that suggests how to approach major changes to hand hygiene infrastructure. A full-scale model can be used to optimize hand hygiene infrastructure prior to construction. During the design phase of one new hospital build, a mock-up of a patient room was built and different dispenser configurations were trialed. 294 There were significant differences in observed hand hygiene compliance when alcohol-based hand rub dispensers were installed in different locations. The investigators noted that the cost of the mock-up was a small fraction of the potential cost of remediating a design flaw that might have reduced patient safety and necessitated work-arounds. 295 Anderson and colleagues suggest that principles of human factors engineering should be applied during the design phase of construction and renovation. 296 They provide the following examples of how the principles can be put into action during changes to hand hygiene infrastructure: • •

• • •

•

Minimize the complexity of cleaning hands (for example, make hand hygiene product dispensers highly visible and install them at a convenient height, in accessible locations, close to other hand hygiene accessories) Use design features that force health care personnel to perform desirable hand hygiene behaviors (for example, install foot faucet controls and automated paper towel dispensers that compel health care personnel to avoid touching contaminated faucets and dispenser surfaces after washing their hands) Minimize the time spent on hand hygiene (for example, conduct work flow analyses to identify when and where hand hygiene is required, so that product dispensers can be installed where they are needed) Provide cues to prompt health care personnel to perform hand hygiene (for example, locate product dispensers consistently by the door of every patient room, or add brightly colored stickers to the dispensers) Assess the usability of any new hand hygiene system, including a simulated interaction of typical users with the item (for example, ask the vendor of an automated hand hygiene monitoring system to report their usability tests, or to supply material and equipment to the hospital for testing) Test new equipment under real-life conditions (for example, install a few new sinks and faucets in an environment typical of where they will be widely used, and solicit feedback from all disciplines through observation and interviews)

During the design phase, architects need specific information from infection preventionists. Farrow and Black note that when infection preventionists work with architects to design new spaces, the discussion is often superficial.297 As a result, infection prevention concerns take a back seat to other design drivers. To ensure that infection prevention concerns are addressed, they recommend that infection preventionists provide explicit details of the processes that will take place in the space, and the pathogens that are of concern. For example, if patients with C. difficile diarrhea are routinely placed in private rooms rather than ward rooms, that fact will inform decisions about how to prioritize additional handwashing sinks during a renovation. 298 A team is needed to successfully modify hand hygiene infrastructure, because members of different disciplines will identify different issues. Anderson notes, “Engineers, for example, will see issues from a reliability and maintenance perspective, whereas educators will see

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opportunities from an implementation and training perspective, and nurses will see ‘flaws’ from daily operational perspective.” 299 A report of the installation of more than 20,000 new hand hygiene product dispensers in more than 100 facilities in one health care system emphasized the importance of a team approach. 300 The authors recommended collaborating with stakeholders from the following departments: • • • • • • • •

Infection prevention and control Facilities management Purchasing Fire safety Environmental services Occupational health and safety Patient care providers Product vendors

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Best Practices and Recommendations Sinks • • • • •

• • • •

The number, type and location of handwashing sinks should be informed by the infection control risk assessment and FGI Guidelines. Provide designated handwashing sinks in addition to sinks used by patients. Ensure handwashing sinks are easily accessible to health care personnel and others. Ensure that facilities for disposal of liquid waste are easily accessible, so that handwashing sinks are not used for waste disposal. Although the minimum acceptable distance between sinks and patient beds has not been established, it would be prudent to install sinks more than 1 meter from the patient’s bed. Consider installing a splash barrier between sinks and nearby preparation and medication areas. Choose sinks with basins deep enough to minimize splashing. Construct sinks and casework of materials that prevent leaks and are easily cleanable. Designate space near the sink to post instructions for correct handwashing technique.

Faucets • • • • • •

Faucet design should be informed by FGI Guidelines. Install faucets that are operable without using hands (for example, with foot controls or wrist blades). Sensor-regulated faucets in areas housing immunocompromised patients. Where sensor-regulated faucets are used, they should meet user need for timing of flow and temperature, and should remain operable during a power outage. Ensure faucets direct water at an angle away from the drain and at moderate pressure. Avoid aerators on hand hygiene sink faucets.

Hand Towels and Dryers • • • • • • • •

Choose paper towel dispensers that can be operated without touching the dispenser. Paper towel dispensers should be intuitive to use and easy to refill correctly. Install paper towel dispensers within arms’ reach of the sink. Avoid air dryers in areas where noise or dispersion of bacteria would present a risk to nearby patients. If warm air hand dryers are installed, installing paper towel dispensers would provide desirable redundancy. Choose air dryers that can be easily cleaned to prevent build-up of lint and dust. Position garbage bins within arms’ reach of paper towel dispensers. Garbage bins should not have lids.

Product Dispensers • • •

Automated dispensers are preferable to manual dispensers. Dispensers should employ disposable cartridge refills that do not require topping up. Choose product dispensers for soap, lotion, alcohol-based hand rub and surgical hand scrub that are easily distinguished from one another.

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• • • •

Consider color-coding dispensers by type: pink for soap, yellow for lotion and blue for alcohol-based hand rub. All products—soap, lotion and alcohol-based hand rub—must be chemically compatible. Install a soap dispenser at every handwashing sink. Install a lotion dispenser at every handwashing sink.

Alcohol-Based Hand Rub • • • • • • • • •

Adhere to the NFPA 101: Life Safety Code® recommendations for volume of alcoholbased hand rub allowable in a single smoke compartment. Install one alcohol-based hand rub dispenser outside the doorway to every patient room, within arms’ reach of the door. Install one alcohol-based hand rub dispenser at every patient bed, either wall-mounted within arms’ reach of common health care personnel positions, or at the foot of the bed. Install alcohol-based hand rub dispensers in locations that are easily visible and consistent from room to room. Consider installing an additional alcohol-based hand rub dispenser just inside the doorway to every patient room. In areas housing patients who are suicidal or confused, consider issuing personal, wearable alcohol-based hand rub dispensers to health care personnel. Choose alcohol-based hand rub dispensers that have drip trays and flags to indicate when they are nearly empty. Install alcohol-based hand rub dispensers at a height of 85 to 110 cm above the finished floor. Instruct health care personnel to ensure alcohol-based hand rub has evaporated completely before igniting a match or lighter.

Electronic Hand Hygiene Monitoring Systems Consider installing an electronic system for monitoring hand hygiene compliance. When making purchasing decisions for an electronic hand hygiene monitoring system, consider the following twenty questions: 1. Do existing dispensers need to be replaced? 2. Can all types of dispensers be monitored (for example, table-top and personal dispensers, soap and alcohol-based hand rub dispensers)? 3. Will re-wiring be necessary? 4. Will data be uploaded and stored automatically? 5. If wireless, will the system affect existing networks or medical equipment? 6. How will the system affect existing work flow patterns? 7. Will the system require health care personnel to change their behavior in any way (for example, to wear badge or respond to prompts)? 8. How are alerts or prompts delivered? 9. How often will batteries need to be replaced? 10. Does the system monitor individuals or groups? 11. Is the system acceptable to health care personnel? 12. How will data generated by the system be accessed, and by whom? 13. How will the data be used (for example, as part of annual performance reviews)?

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14. What inputs will be needed to calculate hand hygiene compliance (for example, census or staffing data)? 15. How will information from the system reach front-line personnel (for example, automatically generated emails)? 16. Is the timing and format of reports customizable? 17. Does the system fit the mission and culture of the organization? 18. What has been the experience of other facilities that have installed this system? 19. Can the system be trialed in the facility before purchase? 20. What are the estimated initial and ongoing costs? Construction Design Process • • • • • • •

Assemble an interdisciplinary team of advisers to guide changes to hand hygiene infrastructure. Discuss hand hygiene processes in explicit detail with the architect. Consider all processes associated with hand hygiene together (for example, consider gloves as part of hand hygiene). Conduct work flow analyses and interview or observe health care personnel to identify design deficiencies. Ask vendors for results of their usability studies for any new equipment being considered (for example, foot-controlled faucet). Conduct a small-scale test of any new product or design before full-scale implementation. Use a full-scale model to optimize hand hygiene infrastructure prior to construction.

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Case Studies Facility C: Adapting to a new work flow configuration As an infection preventionist, Linda has been involved in many construction and renovation projects over the years at Hospital C. In the summer of 2016, the hospital began renovating its emergency department (ED) with the aim of improving patient flow and reducing wait times by building in efficiencies for clinical staff. The ED was built in the 1960s and had undergone several updates. There were 12 private rooms, two 2-bed rooms, and no open bays. There was a sink in every room; some were in the far corners of the rooms and others were at room entrances. The sinks had wrist blade faucets, and the paper towel dispensers were automatic. Linda did not recommend changes to these items. She is wary of electronically operated faucets because poor temperature and time control can be an issue for users, and the additional interior parts can develop biofilms. There are lotion dispensers at sinks in restrooms and at the nurses’ station. The new patient rooms would be designed to support a doctor on one side of the patient bed and a nurse on the other side, with essential supplies located within pivoting distance. The project involves minor renovations such as relocating fixtures, patching and painting. The rooms were closed and renovated one at a time. Each room had a different floor plan, necessitating an assessment of the best dispenser locations for each room. Linda attended one planning meeting. She also conducted a walk-through after the first room was renovated. With the benefit of experience, Linda has learned that dispenser and glove locations should be decided by front-line staff after the project is nearly completed. She noted that since the Life Safety Code® was revised to allow for a large volume of alcohol-based hand rub within each smoke compartment, she was able to recommend an alcohol-based hand rub dispenser be mounted inside and outside the entrance to each patient room. On the day of her walk-through, Linda saw that the proposed dispenser locations (indicated by sticky notes) were not ideal. With immediate input from the emergency department nurses and physicians, she identified new dispenser locations. Staff in the emergency department are satisfied with the hand hygiene infrastructure in their newly renovated space.

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Facility D: Low hand hygiene compliance in perioperative areas In 2015, the perioperative areas at Hospital D were struggling with low hand hygiene compliance rates. The preoperative holding area and post-anesthetic care unit, which had been built more than 40 years prior, were configured as open bays with multiple beds separated by curtains. Dispensers of alcohol-based hand rub were located at the entrance to the unit, at the nurses’ station and on desks around the periphery of the unit; however, there were no dispensers near the patients because wall space was very limited. The infection preventionist Shawn sought the assistance of human factor and system engineers at his hospital to resolve this patient safety issue. The team invested time walking around the spaces, observing work flow and talking with front-line staff. They identified lack of access to alcohol-based hand rub at the point of care as a problem. They also suspected that the cluttered environment, which made the unit appear unorganized and not clinical, might be negatively influencing hand hygiene behavior. Shawn and the team met with managers and directors and the vice president of medical affairs to discuss the challenges and possible fixes. In addition, Shawn asked the vendor of the alcohol-based hand rub product to source a delivery method that would suit the confined space. The automated dispensers in use in other areas of the hospital were too big to fit in the limited wall space of the perioperative units. The team’s solution was to install wall brackets to hold pump bottles of alcohol-based hand rub at the head of each patient bed. In each cubicle, the dispensers were mounted on the wall opposite to where the curtains would be stacked back when open, to avoid hiding the dispensers. A colorful pinwheel was displayed above each new alcohol-based hand rub dispenser to draw attention to its availability. In addition, in the postanesthetic care unit, mobile units of alcohol-based hand rub were clamped to the overbed table at each cubicle. Both units were decluttered. Since the changes were made, Shawn has received positive feedback from staff, and none of the dispensers have had to be relocated. Hand hygiene compliance rates remained unchanged in the preoperative area, but have improved in the post-anesthetic care unit. Shawn attributes this success to using a team approach. Combining the user knowledge of front-line staff with the fresh, objective views of the human factors engineering consultants resulted in simple solutions.

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Facility E: Constant construction Hospital E is part of a large academic health care delivery system that is constantly evolving in concert with medical science. A continuous cycle of renovation and construction is part of that evolution. The rebuilding cycle presents problems for Hospital C on two levels. During construction, patients are at risk for infection because of mold-laden dust and utilities service interruptions. Even after construction is complete, the risk of infection can be indirectly increased if the design of the new space discourages good infection control practice. To avoid design and construction problems, Hospital E dedicated one full-time infection preventionist to consult on all construction and renovation projects. Richard has been an infection preventionist for more than 30 years, and has specialized in construction and renovation for the last ten years. Each year he is responsible for about 100 projects at Hospital E and its affiliates. Richard ensures that hand hygiene infrastructure is not lost among multiple competing priorities. He is notified of every new project at the feasibility phase, and his signature is required at the design development phase. He participates in project meetings to ensure that optimal function is not sacrificed for aesthetic appeal, and that resources are directed to features that offer good infection prevention value for money. Although many of the project architects specialize in hospital design, they are not as familiar with the day-to-day work flow in clinical areas as Richard is. Instituting a full-time infection preventionist to consult on renovation and construction has resulted in a built environment that supports good infection control practices. Alcohol-based hand rub dispensers are available inside and outside of every new patient room and between the beds in multi-patient rooms. Wall space is reserved for alcohol-based hand rub dispensers despite the need to also locate art work, signage, televisions, light switches, outlets, thermostats, glove box holders and sharps containers. Dispensers are placed in locations suggested by front-line personnel. Alcohol-based hand rub dispensers are located where there is no sink, rather than at the sink. Hand soap is dispensed from disposable cartridges rather than the prettier refillable soap dispensers originally suggested. Handwashing sinks are present in each new corridor despite the fact that they spoil the aesthetic line. Wherever possible, sinks are located in the same position in each new patient room even though a lack of variation is considered boring by designers. Renovated rooms are retrofitted with custom-made trapezoidal sinks. Such hand hygiene-friendly features would not have been incorporated into the building without the input of the infection preventionist.

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Facility F: Visualizing work flow during the design of a new hospital Hospital F is a new 270-bed hospital that accommodates patients needing complex continuing care, restorative rehabilitation, geriatric assessment, palliative care and behavioral health care. Jim and Kathleen, two of the infection preventionists at the old hospital, were part of the team responsible for overseeing the new build. Designated subject matter experts from other departments, including front-line clinical staff, were also on the team. The subject matter experts were happy to be able to have a say in how the new hospital was designed, but when asked for their comments during the initial design phase, team members had difficulty thinking beyond their current circumstances and existing work-arounds. For example, nurses asked that toilets in the new facility be positioned so that a commode could be wheeled into place over the toilet. They weren’t aware that plans were already in place for the new hospital to have ceiling lifts in each patient room, with tracks going from above the bed into the bathroom, negating the need for a commode in many cases. Imagining work flow was difficult in light of multiple changes. The team also had difficulty visualizing designs that were presented in two-dimensional drawings. This resulted in problems deciding where to locate hand hygiene infrastructure such as dispensers, sinks and paper towel holders. The solution was full-size model rooms. As part of the contract, the construction company built mock-ups of two patient rooms, as well as a pharmacy workroom, a clean utility room, a soiled utility room and a nursing station. The rooms included the exact dimensions and finishes that would be in the new building, including drywall and paint, flooring, millwork, plumbing fixtures, ceiling lifts and functioning windows. Hand hygiene dispensers were taped to the wall so that they could be tested in different locations. The mock-ups were built at the old hospital in a central location near the cafeteria, and were in place for more than two years. Patients, nurses, therapists, environmental service personnel, administrators and doctors toured the mock-ups and offered comments. Project managers were present to facilitate discussion and record decisions when groups of subject matter experts toured the mock-ups. As a result of the mock-up rooms, team members were able to offer sound advice about hand hygiene infrastructure. For example, a detailed discussion about work flow in the pharmacy resulted in relocation of the handwashing sink. The original sink location in the soiled utility mock-up was also changed. In the patient room mock-up, alcohol-based hand rub dispensers were relocated away from the sinks and soap dispensers; other alcohol-based hand rub dispensers were moved lower on the wall to be accessible to patients in wheelchairs. Manual hand pumps of alcohol-based hand rub were changed to automated dispensers in areas housing geriatric patients with limited strength and mobility. Without the mock-ups, important design details such as these may have been missed, resulting in additional renovation after occupancy, with associated costs, delays and risks to patients.

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Tools Suresh and Cahill designed two checklists that can be used to evaluate the ergonomic fitness of hand hygiene infrastructure including sinks, waste receptacles, alcohol-based hand rub, and gloves (SWAG). 301 The first is a structural checklist and the second is a periodic assessment. Both tools assess the “hand hygiene-friendliness” of the setting. The SWAG structural checklist (see Figure 5) would be very useful to infection preventionists who want to look for gaps in hand hygiene resources in their existing facilities with a view to correcting deficiencies in a new or renovated space. Cure, Van Enk & Tiong developed a method to evaluate various alcohol-based hand rub dispenser configurations for a given patient care unit. 302 The method involves two stages: first determining candidate locations and then determining optimal locations. Three criteria are used to evaluate potential locations: usability, standardization and conformity with regulations and organizational policies. Regarding usability, the authors present a seven-item checklist of characteristics of user-friendly dispenser locations (see Table 1). In stage one, planners identify components that are common to all rooms in the unit (for example, bed or examination table, cardiac monitor, computer, door), record work flow around these reference components and assess the usability of existing and candidate locations with the seven-item checklist. In stage two, planners enter the data obtained during stage one into a decision support model. The mathematical model involves complex formulas, and therefore stage two may not suit everyone’s needs. The method may be used in any health care setting. Chagpar and colleagues developed a toolkit for improving hand hygiene infrastructure, which is distributed by the Canadian Patient Safety Institute. 303 The kit is divided into three tools: an environmental assessment tool, a product selection tool and a maintenance process tool. The tools list the human factors rationale behind each recommendation so that facilities can adapt the recommendations to suit their needs and still adhere to the underlying logic. The toolkit can be downloaded from http://www.patientsafetyinstitute.ca/en/toolsResources/pages/humanfactors-toolkit.aspx. The WHO created a Ward Infrastructure Survey that is available at http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/. The tool is a survey of basic hand hygiene infrastructure that should be available on all hospital units. It could be used to compare hand hygiene fixtures and supplies across different units or facilities, to prioritize renovation requirements. It could also be used as a foundation for assessing gaps in the existing environment with a view to correcting deficiencies in a new or renovated space.

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Figure 5: SWAG* Tool for Assessment of Hand Hygiene Resources in Health Care Environment: Structural Assessment

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Table 1: Usabillity characteristics of dispenser locations with respect to patient care areas (patient rooms)

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Fusch, C., Pogorzelski, D., Main, C., Meyer. C. L., El Helou, S., & Mertz, D. (2015). Selfdisinfecting sink drains reduce the Pseudomonas aeruginosa bioburden in a neonatal intensive care unit. Acta Paediatrica, 104(8), e344-349. 153 Weber, D. J., Rutala, W. A., Blanchet, C. N., Jordan, M., & Gergen, M. F. (1999). Faucet aerators: A source of patient colonization with Stenotrophomonas maltophilia. American Journal of Infection Control, 27(1), 59-63. 154 Sydnor, E. R., Bova, G., Gimburg, A., Cosgrove, S. E., Perl, T. M., & Maragakis, L. L. (2012). Electronic-eye faucets: Legionella species contamination in healthcare settings. Infection Control & Hospital Epidemiology, 33(3), 235-240. 155 Cassier, P., Landelle, C., Reyrolle. M., Nicolle, M. C., Slimani, S., Etienne, J., Jarraud, S. (2013). Hospital washbasin water: Risk of Legionella-contaminated aerosol inhalation. Journal of Hospital Infection, 85(4), 308-311. 156 Hota, S., Hirji, Z., Stockton, K., Lemieux, C., Dedier, H., Wolfaardt, G., & Gardam, M. A. (2009). Outbreak of multidrug-resistant Pseudomonas aeruginosa colonization and infection secondary to imperfect intensive care unit room design. Infection Control & Hospital Epidemiology, 30(1), 25-33. 157 Walker, J. T., Jhutty, A., Parks, S., Willis, C., Copley, V., Turton, J. F., … Bennett, A. M. (2014). Investigation of healthcare-acquired infections associated with Pseudomonas aeruginosa biofilms in taps in neonatal units in Northern Ireland. Journal of Hospital Infection, 86(1), 16-23. 158 Balm, M. N., Salmon, S., Jureen, R., Teo, C., Mahdi, R., Seetoh, T., … Fisher, D. A. (2013). Bad design, bad practices, bad bugs: Frustrations in controlling an outbreak of Elizabethkingia meningoseptica in intensive care units. Jounal of Hospital Infection, 85(2), 134-140.

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44(10), 1095-1101. Munoz-Price, L. S., Riley, B., Banks, S., Eber, S., Arheart, K., Lubarsky, D. A., & Birnbach, D. J. (2014). Frequency of interactions and hand disinfections among anesthesiologists while providing anesthesia care in the operating room: Induction versus maintenance. Infection Control & Hospital Epidemiology, 35(8), 1056-1059. 271 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S162. 272 Larson, E. L., Albrecht, S., & O'Keefe, M. (2005). Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: Comparison of use of 2 dispenser systems. American Journal of Critical Care, 14(4), 304-312. 273 Babiarz, L. S., Savoie, B., McGuire, M., McConnell, L., & Nagy, P. (2014). Hand sanitizerdispensing door handles increase hand hygiene compliance: A pilot study. American Journal of Infection Control, 42(4), 443-445. 274 Babiarz, L. S., Savoie, B., McGuire, M., McConnell, L., & Nagy, P. (2014). Hand sanitizerdispensing door handles increase hand hygiene compliance: A pilot study. American Journal of Infection Control, 42(4), 443-445. 275 Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 23(12 Suppl), S3-40. 276 Kohan, C., Ligi, C., Dumigan, D. G., & Boyce, J. M. (2002). The importance of evaluating product dispensers when selecting alcohol-based hand rubs. American Journal of Infection Control, 30(6), 373-375. 277 Ibrahim, T., & Smith, M. (2003). The dangers of wall-mounted hand gel dispensers [1]. Journal of Hospital Infection, 54(1), 82. 278 Kirk, J., Kendall, A., Marx, J. F., Pincock, T., Young, E., Hughes, J. M., & Landers, T. (2016). Point of care hand hygiene-Where's the rub? A survey of US and Canadian health care workers' knowledge, attitudes, and practices. American Journal of Infection Control, 44(10), 1095-1101. 279 Bush, K., Mah, M. W., Meyers, G., Armstrong, P., Stoesz, J., & Strople, S. (2007). Going dotty: A practical guide for installing new hand hygiene products. American Journal of Infection Control, 35(10), 690-693 694p. 280 Chagpar, A., Banez, C., Lopez, R., and Cafazzo, J. A. (2010). Challenges of hand hygiene in healthcare: The development of a tool kit to create supportive processes and environments. Healthcare Quarterly, 13(Spec No), 59-66. 281 Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 23(12 Suppl), S3-40. 282 Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 23(12 Suppl), S3-40. 283 World Health Organization. (2009). WHO guidelines on hand hygiene in health care. First 270

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global patient safety challenge clean care is safer care. Accessed February 29, 2016, from http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf 284 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S155-178, 151p. 285 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S155-178, 151p. 286 Conway, L. J. (2016). Challenges in implementing electronic hand hygiene monitoring systems. American Journal of Infection Control, 44(5 Suppl), e7-e12. 287 Srigley, J. A., Gardam, M., Fernie, G., Lightfoot, D., Lebovic, G., & Muller, M. P. (2015). Hand hygiene monitoring technology: A systematic review of efficacy. Journal of Hospital Infection, 89(1), 51-60. 288 Srigley, J. A., Gardam, M., Fernie, G., Lightfoot, D., Lebovic, G., & Muller, M. P. (2015). Hand hygiene monitoring technology: A systematic review of efficacy. Journal of Hospital Infection, 89(1), 51-60. 289 Conway, L. J. (2016). Challenges in implementing electronic hand hygiene monitoring systems. American Journal of Infection Control, 44(5 Suppl), e7-e12. 290 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S155-178, 151p. 291 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S155-178, 151p. 292 Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 23(12 Suppl), S3-40. 293 Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N.,…Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35, S155-178, 151p. 294 Birnbach, D. J., Nevo, I., Scheinman, S. R., Fitzpatrick, M., Shekhter, I., & Lombard, J. L. (2010). Patient safety begins with proper planning: A quantitative method to improve hospital design. Quality & Safety in Health Care, 19(5), 462-465. 295 Birnbach, D. J., Nevo, I., Scheinman, S. R., Fitzpatrick, M., Shekhter, I., & Lombard, J. L. (2010). Patient safety begins with proper planning: A quantitative method to improve hospital design. Quality & Safety in Health Care, 19(5), 462-465. 296 Anderson, J., Gosbee, L. L., Bessesen, M., & Williams, L. (2010). Using human factors engineering to improve the effectiveness of infection prevention and control. Critical Care Medicine, 38(8 Suppl), S269-281. 297 Farrow, T. S., & Black, S. M. (2009). Infection prevention and control in the design of healthcare facilities. Healthcare Papers, 9(3), 32-37. 298 Farrow, T. S., & Black, S. M. (2009). Infection prevention and control in the design of healthcare facilities. Healthcare Papers, 9(3), 32-37. 299 Anderson, J., Gosbee, L. L., Bessesen, M., & Williams, L. (2010). Using human factors engineering to improve the effectiveness of infection prevention and control. Critical Care Medicine, 38(8 Suppl), S272. 300 Bush, K., Mah, M. W., Meyers, G., Armstrong, P., Stoesz, J., & Strople, S. (2007). Going

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dotty: A practical guide for installing new hand hygiene products. American Journal of Infection Control, 35(10), 690-693 694p. 301 Suresh, G., & Cahill, J. (2007). How "user friendly" is the hospital for practicing hand hygiene? An ergonomic evaluation. Joint Commission Journal on Quality & Patient Safety, 33(3), 171-179. 302 Cure, L., Van Enk, R., & Tiong, E. (2014). A systematic approach for the location of hand sanitizer dispensers in hospitals. Health Care Management Science, 17(3), 245-258. 303 Chagpar, A., Banez, C., Lopez, R., and Cafazzo, J. A. (2010). Challenges of hand hygiene in healthcare: The development of a tool kit to create supportive processes and environments. Healthcare Quarterly, 13(Spec No), 59-66.

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CHAPTER 3: Reprocessing

Frank Myers, MA, CIC, Infection Preventionist, University of California-San Diego Introduction Currently in the United States, the minimum standard for whether an item is reprocessed using low level disinfection, high level disinfection (HLD) or sterilization is determined by the Spaulding scheme. 304 Items touching intact skin or the environment need low level disinfection at a minimum (for example, a wheelchair, stethoscope, blood pressure cuff, pulse-oximeter, etc.). Items coming into contact with mucous membranes and non-intact skin receive HLD at a minimum (for example, vaginal ultrasound probe, endoscopes, etc.). If an item touches a sterile site it must be sterilized (for example, surgical instruments). HLD kills most organisms, although it will not kill 100 percent of bacterial spores. Sterilization is a process that destroys or eliminates all forms of microbial life including spores. The sterilization process can be divided into five steps. The first step is gross decontamination. This is the removal of gross debris on the item and treating the item in a way that will not allow for the drying of the material on the device. Because timeliness is of the essence, there are no environmental requirements for where one can perform gross decontamination. The next four steps do have environmental requirements. These steps are decontamination, packaging for sterilization, sterilization and storage of the material for use. Each of these steps has unique requirements for the environment. For example, the decontamination room, where the instruments have the final rinse through before either being wrapped or entering a washer decontaminator, should be done in a location that has—at minimum—a three-bay sink. The type of sterilizer used at a facility will determine to a large extent the facility’s needs for heating, ventilation and air conditioning as well as area and room design. The most frequently used sterilizers in health care facilities can be divided into several groups: table top sterilizers, steam sterilizers, hydrogen peroxide plasma sterilizers and peracetic acid sterilizers. Table top sterilizers, because of their comparatively small size and capacity, have little in the way of infrastructure demand, while steam sterilizers have a need for separate access to the sterilizer for repair and maintenance issues as well as careful placement of the supply ducts for cool air. Poor placement of these ducts immediately above the sterilizer door can result in condensation forming on metal instruments (i.e., “wet load”) rendering them no longer sterile. The quality of steam and water supplied to a steam sterilizer is also important as “wet steam”, which can cause the sterilization process to fail and “hard water” may also shorten the life of a sterilizer because of calcium deposit build up. Temperatures for hydrogen peroxide plasma sterilizers are lower and thus the demands on the facility infrastructure are lower. Ethylene oxide sterilizers were steadily losing market share in the United States until recent outbreaks related to duodenoscopes suggested this technology might be effective at stopping these events. However, because of the safety issues around ethylene oxide and the need for material having gone through the process to be stored for a period of time before use, the infrastructure demands around these machines are quite extensive. Peracetic acid sterilizers are usually small sterilizers that can be placed in many areas with limited infrastructure needs. In addition to the various building codes and sterilizer requirements, the three documents reviewed below are the most frequently used when reviewing the guidance around the environmental needs for each of the steps of the sterilization process. These documents include

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the Association for the Advancement of Medical Instrumentation (AAMI) ST79: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, Healthcare Infection Control Practices Advisory Committee 2008 and guidance from the Association of periOperative Registered Nurses. These documents set the minimum standards for water and air quality and temperature and humidity in these areas. In addition, they set standards for lighting needs; work flow, generally from to dirty to clean; air pressure relationships; and other design issues. Some of these requirements are based on scientific literature review, while other requirements are based on expert opinion and consensus. Thoughts and standards around high-level disinfection are changing perhaps more rapidly than those around sterilization. Recent outbreaks have demonstrated that past approaches to high level disinfection put patients at greater risk than previously recognized. Additionally, the Spaulding scheme is being questioned for some items undergoing high level disinfection as instruments that are sterilized frequently have very low bioburdens on them after use, while endoscopes have very high bioburdens, meaning that high-level disinfection has a very thin margin of safety. Some items like vaginal probes continue to have high level disinfection as the unquestioned standard. Some of the current standards around high-level disinfection air pressure requirements are changing because requirements for safety around spills of high level disinfection fluids imply one air pressure relationship with the surrounding rooms while current design standards suggest another. The differences between vaginal probes and complex endoscopes result in different standards for these devices. For example, AAMI ST91: Flexible and Semi-rigid Endoscope Processing in Health Care Facilities and guidelines of the Society of Gastroenterology Nurses and Associates, Inc., can be consulted for endoscopes but these do not apply to vaginal probes, therefore, this chapter will deal with these devices separately. The high-level disinfection process has four steps. The first is gross decontamination, and like the gross decontamination step in sterilization, this first step is usually done at the point of use immediately after patient care. In the case of endoscopes, this process may involve a few steps, while in the case of vaginal probes it may simply involve removing the condom sheath. The second step is cleaning the scope or vaginal probe; third is high level disinfection, and fourth, storage. The cleaning step for endoscopes involves at a minimum the use of a two-basin sink. When an item has been exposed to high level disinfection, the chemicals that are toxic need to be removed. Most high-level disinfection for endoscopes today is done in automated endoscope reprocessors. Most modern automated endoscope reprocessors have filters to remove bacteria normally found in potable water from the water used for rinsing. Automated endoscope reprocessors also have specific water pressure needs. For institutions that do not use automated endoscope reprocessors for all their scopes and also reprocess manually, a plumbed source of fresh water should exist. Additionally, most automated endoscope reprocessors now have a cycle that flushes air through the scope to ensure drying, but if that is not available, a source of medical grade air should be available. Disposal of the high-level disinfectant can also require deactivation before discharge to sanitary sewer. This depends in part on the manufacturer’s instructions for use and the local water authorities regulations.

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Several basic actions that will minimize error in the steps described above have been established. Decontamination in the sinks for either high level disinfection or sterilization requires that all visible debris be removed from the object; functionally this means that the area where this is performed requires excellent bright lighting with a minimum of shadows. For decontamination for both high level disinfection and sterilization, staff must wear personal protective equipment that is waterproof or water-resistant. This personal protective equipment is not breathable, meaning that staff can quickly overheat and as a result become distracted and not perform in the same manner as if they were comfortable. The concern over staff comfort has resulted in different room standards for temperature ranges. Unfortunately, personal protective equipment does not allow for cool outside air to penetrate and reduce the heat load of the staff working in that area. The decontamination area for both sterilization and high-level disinfection should be an area designed to withstand copious water exposure without promoting fungal growth. Materials such as wood or pressboard should not be used in these areas. Additionally, walls should be made of a material that will not allow for fungal growth if it is saturated with water. The design of decontamination and processing areas for both high level disinfection and sterilization needs to reduce staff interruption and distraction. This functionally means the areas should be restricted from others entering, which can be accomplished by installing a numeric keypad lock or another lock that cannot be lost but that will prohibit unauthorized personnel from entering the area. Some institutions have begun using borescopes during the reprocessing of endoscopes. They are traditionally used immediately before the scope is to be placed in the automated endoscope reprocessor (AER). These borescopes normally require a connection to a computer, so if borescopes are to be used, there will need to be space planned for the computer and related electrical needs. Brief Literature Review Specialized equipment used in high level disinfection and sterilization requires that some preplanning data gathering needs to be conducted. Water hardness needs to be evaluated for two reasons. For devices such as washer disinfectors used in decontamination for sterilization, hard water deposits can result in buildup that can obstruct water flow used to clean items inside the machine. Additionally, hard water can result in mineral deposits on the instruments being processed inside the machines, rendering the instruments unable to be used or sterilized. Hard water also reduces the rate of kill of some disinfectants because divalent cations such as magnesium and calcium in the hard water form insoluble precipitates when they come into contact with certain disinfectants. 305 Additionally, hard water may cause a buildup of deposits inside the automated endoscope reprocessors. Steps must be taken to evaluate whether the water is hard and mitigations have developed so that hard water does not negatively affect the sterilization and/or high-level disinfection processes. 306 Water hardness is defined as the presence of calcium carbonate in the water in concentrations above 61 micrograms per liter. Water in with a concentration of 61-120 mg/l is considered moderately hard, 121-180 mg/l is defined as hard and above 180 mg/l is very hard 307. Although fewer and fewer facilities are using ethylene oxide sterilization it has enjoyed a very modest increase in its use because of some high profile endoscopic retrograde cholangio-

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pancreatography (ERCP) duodenosocpe outbreaks and Federal Drug Administration guidance. 308 Humidity outside of the range of 40 to 80 percent can cause failure of the sterilization process. 309 If an ethylene oxide sterilizer is being installed, a heating ventilation and air conditioning unit that is capable of maintaining this range without failure needs to be installed. Enclosed containment areas with additional ventilation requirements are recommended for ethylene oxide sterilizers and other chemical sterilizing agents. 310,311 Automated endoscope reprocessors generally require an electrical source, a water source and ability to dispose of waste solutions via the sewer system. In the past, some high-level disinfectants like OPA (ortho-phthalaldehyde) have had requirements added after their introduction to inactivate the disinfectant before disposal. The automated endoscope reprocessors at the time had not planned for this additional step, so facilities had to design postinstallation changes to allow for it. Planning for such space around an AER may be prudent. Some newer automated endoscope reprocessors have cleaning claims, and these machines have higher washer pressure requirements than are traditionally found in most endoscopy suites. Whether these automated endoscope reprocessors will gain market share or not is unclear, but it is reasonable to consider that they may be used in any area where endoscopes are reprocessed and water pressure should be capable of handling their minimum demands. Cart washers are devices that wash carts used to transport dirty surgical equipment between the operating rooms and the sterile processing department. They have become standard in most newly constructed U.S. hospitals. Because these devices are automated, they largely eliminate the potential for a blood borne pathogen exposure to staff cleaning the carts and ensure a standard level of cleaning. Cart washers also minimize the need for an area to be set aside for manual cart cleaning. Again, since these devices use copious amounts of forced water, plans for the area should involve evaluating for hard water and, if necessary, remedying; access for repairing the cart washer, and sewering the runoff. Larger steam sterilizers (not table top sterilizers) require several sets of criteria. The steam supply to the sterilizer must be through lines that have sufficient insulation to prevent “wet steam,” adequate (high) steam pressure to prevent “superheated steam” and drain lines with the capacity to handle the volume of water generated at the end of steam sterilization. Steam dryness should be between 97 and 100 percent. The level of noncondensable gases (that is, air), expressed as a fraction by volume, should be at a level of less than 3.5 percent v/v condensate. This level will not impair steam penetration into sterilization loads. 312 Steam should not reach a temperature above 25°C (77°F) of the saturation point. 313 The boiler feedwater source, treatment chemicals used and the design and maintenance of the steam supply system should minimize the presence of potential contaminants in the steam; this means treating hard water before it enters the boiler. Steam lines should be designed to eliminate any “dead legs.” Dead legs are areas without a continuous flow of steam and these legs can harbor and propagate contaminants, including microorganisms. The lack of a flow of steam can result in condensation that allows bacteria like Pseudomonas to reproduce and form a biofilm. 314 In-line filters should be installed as close to the sterilizer as possible, and they must include a drip leg or trap so condensate can be removed. Steam sterilizers also require an access room so that repairs may be conducted. These rooms are under negative pressure to the surrounding areas. Because these rooms are not designed for staff regular use, they are often without adequate heating, ventilation and air conditioning

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capacity. However, plans should include ways to minimize the extensive heat load in these rooms from affecting the temperatures in surrounding rooms. Additionally, the heat load and humidity in these rooms should not exceed the standards set by the local Occupational Safety and Health Administration jurisdiction for worker safety 315 as the areas become staff work areas for repairs maintenance. The cooling cannot be excessive in these rooms or the function of the sterilizer may be affected. The Facility Guidelines Institute (FGI) Guidelines of 2014 316 require ten air exchanges an hour for these rooms with a direct exhaust outside. The steam sterilizers themselves generate heat that escapes the sterilizer once the door is open. As mentioned above, supplies of cool air cannot be placed so that cool air blows directly on still-hot sterilized packs, as that will compromise the sterilization process; however, this heat does need to be mitigated for the rest of the work area. To be effective, high-level disinfectants require set temperature ranges. These can occur at temperatures slightly above some staff comfort zones. Most automated endoscope reprocessors will warm the disinfectants during their use. Some facilities still perform manual high-level disinfection. Manual high-level disinfection is a problem-prone process, and studies show that the process occurs as delineated in the endoscope instructions less than 2 percent of the time. Nevertheless, a facility may still perform high level disinfection manually, in which case additional electrical supply may be necessary for a warmer for the disinfectant and, in some cases, a hood to capture potentially harmful fumes from the disinfectant. To this point the chapter has reviewed the factors that are generally agreed on and evidence based. The issues of room temperature, room humidity and pressure differentials between reprocessing areas and adjacent spaces takes us out of those elements. Temperature, excluding the elements discussed above, has to do with staff comfort. Comfortable staff work more effectively, but what feels comfortable is unique to each individual. Attempts to formulate guidelines around temperature have resulted in some contradictory guidelines. AAMI ST79 (2013) listed temperatures for the decontamination room that were below and did not overlap the guidelines given by the FGI 317 and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). 318 This listing had to do in part with the experience of some of the members of the AAMI group working in those areas. Individual comfort can be influenced by the individual’s age, physical fitness, body mass index and current workload; what is comfortable to a fit 90-pound young person in a decontamination area that only deals with relatively light eye sets in low volumes can be far too warm for an obese older person working to decontaminate heavy sets in a high-volume area. Additionally, as mentioned above, the personal protective equipment worn in decontamination for either high level disinfection or sterilization is not breathable and therefore the effect of lowering the outside temperature to increase staff comfort is marginal. Consensus on a group from the AAMI, Association for Professionals in Infection Control and Epidemiology (APIC), Association of periOperative Registered Nurses (AORN), FGI and ASHRAE studying this issue is that cooling vests worn by staff maybe a better answer to staff comfort than lowering the temperature of the decontamination area. This conflict was finally eliminated in the 2017 AAMI standard. Another reason cited for lower temperatures in decontamination areas, specifically for sterile processing, is that cooler temperatures retard microbial growth. This ignores that some bacteria are psychrophilic (prefer cold), some are thermophilic (prefer hot temperatures) and many are mesophilic (prefer normal temperature ranges). Most pathogenic bacteria are mesophilic but

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even these have bacteria that replicate well at temperatures within the range of the bottom of those in the AAMI guidelines. 319 Humidity settings also have limited value in preventing infections. Clearly ranges and temperature combinations that cause condensation or precipitation are to be avoided, as the addition of water to a surface will promote growth of fungi and bacteria. Outside of these ranges, a review of the literature shows only prolonged (periods of days to weeks) exposures to high humidity has any meaningful increase in fungal growth. Short excursions into these ranges probably have negligible effects. Low humidity settings when offered have no effect on microbial growth. Short exposure can, however, affect the functional life of paper products used to wrap sterile items. If these papers are exposed to prolonged low levels of humidity they may become compromised. Using pressure differentials to prevent contamination of items about to enter the sterilization process is an approach not supported by scientific studies. While such an approach can work for “clean rooms” where staff are completely encapsulated in a head-to-toe suit, the settings in the preparation and packaging area does not reflect such a work space. Staff routinely work in this area with clean clothes and exposed skin including face, arms and hands. No studies have demonstrated that bacterial loads on instruments entering the sterilizer have any meaningful increase in bioburden because of a failure to maintain positive pressure in this area. The total bacterial count on an instrument handled by bare hands with a person also shedding squamous cells is not meaningfully affected by any microbes floating into the room. Additionally, even if it were to cause a greater microbial load, these instruments are about to enter a sterilizer designed to kill any such microbes. The negative pressure for the decontamination area also has limited data to support its use except around airborne diseases where the source of the microbes is the human respiratory system and not the mechanical action of decontamination. Lastly, the use of chemicals that may emit toxins on the positive pressure side is not unusual. If a large spill were to occur, the potential spread of the fumes from a positive pressure area into other populated areas may be a true concern. Despite the lack of scientific support for current standards around humidity, temperature and pressure differentials, guidelines are written into all existing design and practice standards (AAMI, FGI, ASHRAE) and must be complied with. Best Practices and Recommendations Sterilization and Design from the Point of Use to Reprocessing Back to the Point of Use The sterile processing that occurs in either outpatient surgery centers or acute care hospitals involves several rooms. These rooms must be planned for, although when noted they may not be necessary or may be incorporated into other rooms. The sterile processing area is the overall name for the area within a health care facility that sterilizes items and in some facilities processes and controls medical supplies, devices and equipment both owned and rented, sterile and not sterile, for some or all patient care areas of the facility. A determination of the role and responsibility of the department must be conducted before designing the space. More facilities are moving away from a department that is responsible for both non-sterile supplies, rental equipment such as beds and sterile processing, because often at minimally staffed times these additional responsibilities will interrupt staff while they are performing

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intricate multiple steps involved in sterilization, resulting in inadvertent compromising of the process. The decasing/breakout area or space is the unpacking area or space where products are removed from their external shipping containers before being taken into the preparation and packaging area or the sterile storage area. This area may or may not include an area for the accepting of “loaner trays” from vendors. Loaner trays should be inventoried before the facility accepts them 320,321 and therefore a counter where this can be done should be provided if they are received in this department. A receiving, cleaning and decontamination area is another area where these trays may be received, but its largest volumes come from receiving reusable instruments, supplies, equipment and carts and sorting, cleaning and decontaminating. Generally, the area for cleaning carts and associated equipment should be proximal to the decontamination area. The personnel support area is where staff toilets, showers and locker facilities are available. The preparation and packaging area is where items that have left the decontamination area as decontaminated instruments, or clean instruments, or other medical and surgical supplies are then inspected; assembled into sets and trays; and wrapped, packaged or placed into rigid sterilization container systems for sterilization. These are generally adjacent to the decontamination room and a pass-through window allows for items to move between. Washers/decontaminators also have an entry in both the decontamination room where dirty instruments are placed and the preparation room where they are removed from the machine once they have been through a successful decontamination cycle. The sterilization area is the place where sterilization activities take place. Once items have been successfully sterilized they are moved to the sterile storage area. There they are stored and protected from contamination. This area may also be used to store clean items that are distributed by the department. The equipment and cart holding area is the holding area for clean medical equipment and carts before storage or issue. If the department is also responsible for distribution of nonsterile equipment they will need an equipment storage area where clean medical equipment is stored until issued. An administrative area must exist for the department supervisor to handle human resources issues. An environmental services equipment storage area is where supplies and equipment for cleaning the sterile processing area are kept. Most facilities have moved away from reusable textiles for performing a sterile wrap but if a facility plans on continuing this practice then an area is needed for storage of the linens, inspection of the linens and, if also not outsourced, onsite laundering. Some space must also be designated for the temporary storage of sterilization records. This can be done in many of the areas described above. The flow of these rooms should be unidirectional from dirty to clean. Additionally, the sterile processing areas should be in close proximity to the areas they serve. In cases where this may not be possible, such as when serving both the surgical suites and labor and delivery operating suites, the sterile processing area should be on the same floor as both of its customers. If that is not possible, then a dedicated dirty elevator and a dedicated clean elevator should exist between the sterile processing area and customers on other floors, in addition to a path of travel established allowing for dirty carts to arrive in the decontamination or receiving area in the event of elevator failure, and a path of travel established from the clean side to deliver sterile items back to the unit needing them.

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General design issues for the sterile supply area should be constructed to create a flush surface with recessed, enclosed fixtures. Pipes and other fixtures above work areas should also be enclosed so as to not create a surface for dust to accumulate. Ceilings should be constructed of materials that are not of a particulate- or fiber-shedding composition, and in the decontamination area materials should be resistant to fluids. Floors and walls should be able to withstand fluid exposure 322 and frequent cleaning and should not be adversely affected by the chemical agents typically used for environmental cleaning. Some sterilizer carts have blunt ends that can damage walls, exposing porous fibers that can shed into the environment and then, when washed, absorb water and cause fungal growth. Planning for wall damage from carts and ways to mitigate that damage is prudent. Floors should also be flat without groves as they are difficult to clean. Before determining the space requirements for the sterile processing area, the services the department will provide must be defined as well as the expected inventory of sterile supplies (including disposables) as well as if any non-sterile items will be distributed from the department and how these will be distributed. Additionally, adequate space should be allocated for equipment, and the functional work areas should be designed accordingly. General consideration for the space needs of this area should include at a minimum: • • • • • •

The anticipated volume of work and the units to be served (for example, operating room, anesthesia, delivery room, emergency room, trauma unit, burn units, outpatient clinics, specialty units). Whether washer-sterilizers, washer-disinfectors, washer decontaminators, single- or multi-chamber tunnel washers, cart washers, ultrasonic cleaners or endoscope processors will be used in the department. The types of packaging to be used (for example, disposable wraps and pouches, reusable wraps or rigid sterilization container systems. Most facilities today are moving toward rigid containers for many items. The technology to be used for sterilization (for example, ethylene oxide, other chemical sterilants, steam) in most cases departments use more than one type. The anticipated inventory storage. If an inventory tracking system is used, because plans for this affect the decontamination, pack and sterilization and storage areas.

Space is crucial as a cluttered or crowded space may not allow for staff to move items without recontaminating them. It can also make cleaning of the area difficult. Several questions must be answered before the design of the decontamination area project can go forward. Some facilities have attempted to decentralize decontamination to the departments that are contaminating the instruments in need of sterilization. Such approaches may increase costs to the facility as the special ventilation needs described above have to be replicated throughout the facility. Additionally, challenges with staffing may arise as individuals who work in specific areas become familiar with only those instruments; when these specialized individuals are not present at work the skill level of the replacement staff may not be adequate. Whether the decentralized approach will be attempted must be addressed. The Facility Guidelines Institute’s Guidelines for 2014 requires six air exchanges an hour. The air should be exhausted directly outside and the area should be under negative pressure.

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Staff use of personal protective equipment in the decontamination area can quickly fill large waste receptacles. An area for staff to don and doff personal protective equipment should be established. This area should be free of risk from being contaminated by accidental spraying occurring in the decontamination process. An eye wash station needs to be present in this area and not be likely to cause splash up or back from a contaminated surface. Staff must have access to instructions for use for all items they are decontaminating. Most facilities are moving toward having these be obtained from the Internet and so either Wi-Fi access for tablets (personal electronic devices) or a computer station should be in the design plans. Ergonomic factors affecting worker safety and comfort should be considered when designing work spaces because fatigued or uncomfortable staff may not be as diligent in looking for compromises in the sterilization process. Additionally, the Occupational Safety and Health Administration has standards and expectations for sterile processing areas. 323 For the comfort reasons cited above, sinks should not be so deep that personnel must bend over to clean instruments. Decontamination sinks ideally should be approximately 36 inches (91 cm.) from the floor and 8 to 10 inches (20 to 25 cm) deep. The sink should be of a width and length to allow a tray or container basket of instruments to be placed flat for pretreatment or manual cleaning. The sink should be constructed with three sections—the first for soaking, the second for washing and the third for rinsing—and it needs to have water ports to facilitate the flushing of instruments with lumens. Sinks should be large enough to contain the largest utensils and instruments used in the facility. A source of deionized, distilled or reverse osmosis water for final rinsing should be provided as this will eliminate the hard water issues discussed above and prevent recontamination by microorganisms and endotoxin typically found in potable water. Any minerals found in water used for manual cleaning will likely stay with the instrument through the sterilization process, impairing the instrument and potentially the sterilization process 324 However, automated washers can provide a final rinse with whatever grade of water is made available. Forced air should be provided at the sink, as well as faucets or manifold systems for flushing lumened devices. Sinks should have attached solid counters impervious to water on which to place soiled and clean items separately. Far more important is the lighting for both the decontamination area and the packaging area. The recommendations are based in science and in a range of 1,000 lux (100 foot-candles) to 2,000 lux (200 foot-candles) so that the detailed work of removing bioburden and inspecting for bioburden can be successfully accomplished. Items such as the stainless-steel tables used in both decontamination and packaging, the color of walls and the age of staff must also be taken into consideration when evaluating lighting needs. Additionally, all lighting must be designed so as to not allow for dust accumulation and minimize staff shadows being cast on their work areas. Hand hygiene facilities (sinks and/or waterless alcohol-based hand rubs) should be conveniently located. They should be located in or near all areas in which instruments and other devices are decontaminated and prepared for sterilization, as well as in all personnel support areas (for example, toilets and lounges) to allow staff to quickly reduce the bioburden on their hands. AAMI ST79 recommends the air supply in this area be of the down draft design because of the copious amounts of lint generated in the area. Facility Guidelines Institute Guidelines require only 4 air exchanges an hour. The area should be under positive pressure.

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Sterilizers should be located in a restricted access area to decrease contamination risk, minimize distraction and facilitate appropriate security/release of reprocessed instruments/equipment. The areas where the sterilizers are located should be free of sources of contamination and in low traffic areas. Immediate use (formerly known as flash sterilization) steam sterilizers should be located in the restricted area of the surgical space where personnel are required to wear full surgical attire, including covering all head and facial hair, including sideburns and necklines, and to wear masks in the vicinity of open sterile supplies. Because of guidance to follow the manufacturer cycles described in instructions for use including some nonstandard cycles, consideration may be given to the installation of a separate steam sterilizer designated for use of these medical devices requiring non-routine cycles. The room by AAMI standards should have 10 air exchanges an hour and be under positive pressure. Ironically the FGI did not address this issue because of uncertainty of the relationship between operating suites and the area directly outside operating suites as sterilizers are placed directly outside operating suites and operating suites are under positive pressure. The sterile storage area should be under positive pressure and adjacent to the sterilization room so that contamination cannot occur during transport of the items to this area. The bottom shelves of the storage area should ensure that no contamination occurs during floor care. Solid bottom shelves are preferable. Ideally, items should not be stored under overhead plumbing. The room should have adequate heating, ventilation and air conditioning and insulation so that if one or more of the walls is an exterior wall, external temperatures will not affect the still-warm items that have just been sterilized and cause condensation on any sterile sets. Areas using table top sterilizers are much less restricted in their design requirements although they should be in a clean designated area. 325,326 Whether radiation sterilizers will penetrate the health care facility market is yet to be seen, but those sterilizers require their own set of rules specifically around staff safety rather than infection prevention. One other consideration for sterile processing departments is that the area where biological indicators are incubated after use must be in a temperature and humidity controlled space in accordance to the manufacturer’s instructions for use. The reason is so the results of these tests are accurate and compliance can be achieved either by controlling the overall environment or, in some cases, placing the unit in a humidor-like enclosure. High Level Disinfection from Dirty to Clean Storage Work flow in areas performing high level disinfection must be unidirectional. 327 The environment must support this by allowing adequate space for storage of newly contaminated scopes entering the area. To support infection prevention, the design of the work should incorporate • • • • • • • •

Work flow. Anticipated patient and procedure volume. Number and types of endoscopes/equipment. Quantity and type(s) of processing equipment. Scopes/equipment storage requirements. Supply/chemical storage requirements. Traffic flow. Required utilities (for example, medical-grade air, water quality, ventilation).

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As with sterilization, the pre-clean must occur immediately after the endoscope is used and thus occurs in the procedure room. The processing area must be physically separated from the patient procedure rooms. If an elevator is used for transport of scopes because the reprocessing area cannot be on the same floor as the procedural suites, a dirty elevator and a clean elevator should be dedicated to the transport of either clean or contaminated scopes only. The following items need to be in the endoscope reprocessing area: flat surfaces, lighting and utility support of electricity. The area should be designated solely for the reprocessing of endoscopes. It should have an area for receipt of scopes, cleaning (decontamination), disinfection or packaging and sterilization, and storage. Physical separation of these steps is preferred. An area should be defined at the incoming end of the unidirectional flow process for the receipt and temporary holding of devices before cleaning. This area should be far enough away from the processing sink to not interfere with that process. The sink where leak testing and flushing of the endoscope are performed should be supported by two large flat surfaces on either side. These surfaces should be large enough to hold the longest scope in the inventory. The area should also be supported with cabinetry that holds disinfectants used to clean the flat surfaces in the receiving area or around the sink without requiring staff to leave the area to obtain the disinfectants. The backsplash on the sink shall extend at least one foot up from the sink. Sinks should be deep enough to allow complete immersion of the longest endoscope in the inventory. The sink should also be large enough (that is, 16 inches x 30 inches) to ensure the endoscope can be positioned without tight coiling but not so deep so that personnel have to bend over to clean instruments. Three sinks or one sink with three separate basins should be used, so that each function is performed in a separate sink or basin. As most enzymatic cleaners used in the process are diluted per gallon, the sinks should come with pre-marked gallon fill levels so that staff can quickly determine the correct dilutions for enzymatic cleaning. The sink or sinks should have faucets and adapters that attach to the faucet, or other accessories that facilitate the flushing of instruments with lumens. The sink and surrounding cabinetry should be impervious to water. Lighting should be placed above the sink and counter area so that personnel can adequately perform inspection activities as the endoscope is processed but not have their shadow cast into their work area. Light levels are the same as those described earlier in the sterile processing decontamination area. Ideally a small supply rack should be above the sink, protected from splashing from the sink, so that immediately needed brushes and other equipment are available to staff and not inadvertently placed in the dirty or clean area. Forced air with an upper limit of pressure as described in the endoscope manufacturer's written instructions for use should be provided at the sink for flushing lumened devices. Since these may vary by scope manufacturer, a way to regulate the pressure is needed. Floors and ceilings should comply with the guidelines described in the sterile processing area. As mentioned above, some automated endoscope reprocessors come with a cleaning cycle that eliminates the need for the sinks used for this process. However, not all scopes are validated to be used in such automated endoscope reprocessors. In fact, for duodenoscopes, the Food and Drug Administration (FDA) currently requires that “the automated endoscope reprocessor cleaning cycle only be used as a supplement to thorough manual cleaning according to the duodenoscope manufacturer’s instructions,328 functionally ensuring that for the foreseeable future manual cleaning will continue to play a role in endoscopy reprocessing.

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Some facilities use a machine capable putting the scopes through a sterilization process (for example, STERIS 1E™). Scopes processed thus are not recommended for storage but for immediate use if sterility is to be maintained. If they are stored they should be reprocessed before use unless otherwise stated by the manufacturer. Ideally, after the scopes have been decontaminated they should pass into a separate room where the automated endoscope reprocessors are located. This should be done through a pass-through window. If this is not possible, at an absolute minimum a distance of three feet should separate the dirty processing area and the clean work area. The scopes will then be placed in an automated endoscope reprocessor. This room should have a handwashing sink so staff can easily perform hand hygiene after touching a scope that has yet to be high level disinfected and before touching one that has been high level disinfected. If the AER does not have a final air blow through with or without alcohol for scopes that recommend that, then filtered air should be supplied in this area. Once the scope has been removed from the automated endoscope reprocessor, it should from there be moved to a separate dedicated room where scopes are stored. Storage of scopes is an evolving issue. Consensus is that scopes should not touch the bottom of the scope storage cabinet. A scope cabinet should be able to allow vertical hanging of the longest scope. European scope cabinets with filtered air and drying claims may or may not have a future in the U.S. market. Recent studies showing that scopes having undergone alcohol and forced air are still wet suggest that the future may be moving towards the drying cabinet design 329. In the event that these do gain market share, abundant electrical outlets in these areas should be available. All scope cabinets should be made of material that will not promote bacterial or fungal growth if scopes drip. Ideally the scope cabinet’s floors should be made so that drips are easily visible as a quality check on the drying process. Vaginal probes, because they lack lumens and do not generally encounter the level of gross contamination seen with endoscopes, do not have nearly as many guidance documents around them. Room lighting should be sufficient to detect debris on the probe. Cabinetry should exist for storing the disinfectant solution and the temperature range should be great enough to allow the high level disinfectant to work. A sink is generally needed to wash off the device after being submerged in the disinfectant. A sink to wash the probe prior to insertion in the high level disinfection is generally not required as most probe manufacturers only require the probe to be wiped off with a hospital disinfectant. Ventilation requirements are based more on the toxicity of the disinfectant used than any purported infection prevention benefits. If high level disinfection of these probes were to be performed in a patient care room, it would need to be unoccupied and the high level disinfection solution not be accessible to patients. Multipurpose Rooms Sterilization and high level disinfection are complex processes and the mixing of these complex processes with any other tasks or use areas is likely to result in inferior outcomes as distractions increase. Nevertheless, institutions frequently attempt to maximize existing space with mixed results. The sterilization decontamination process generates copious amounts of water including splashes and requires staff to wear personal protective equipment and use negative pressure. This precludes the process from being mixed with patient care areas. Decontamination areas in older hospitals are often not spatially separated from the packaging area but in one contiguous

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room. In fact the Facility Guidelines Institute’s 2014 Guidelines recommends in such cases a four-foot distance from the edge of the sink to a clean work area or a screen four feet higher than the edge of the sink. This approach is clearly inferior as it does not account for distraction or human behavior that can result in cross contamination. High level disinfection endoscope or vaginal probe decontamination and sterile processing decontamination can be done in the same room. Given the expensive and fragile nature of endoscopes, decontamination of an endoscope should not be attempted at the same time as the decontamination of any other device, such as a vaginal probe or surgical instruments. Attempting to perform decontamination for both instruments in the same space would require separate sinks not because of a risk for cross contamination but so that both could be done in a timely fashion. High level disinfection (automated endoscope reprocessors specifically) and sterilization can be done in the same area. This is specifically seen in a cartoon of an office-based sterile processing area in AAMI ST79. Some sterile items are routinely stored in patient care areas (patient rooms, emergency department treatment rooms, operating rooms), although this has caused some issues. 330 One needs to be aware of the temperature and humidity issues in these areas. Additionally, attempting to access these supplies may disrupt care. High level disinfection and storage should not occur in the same area, and while sterilization rooms may be contiguous with storage spaces, they should have great spatial separation. The most basic reference is the personnel who perform processing in these spaces. Designing an environment for high level disinfection or sterilization without their input will ensure frustration and possibly increased risk of disease transmission. In addition to state regulations, basic guidelines include the Facility Guidelines Institute, the American Society of Heating, Refrigerating and Air-Conditioning Engineers and AAMI ST91 (high level disinfection) and ST79 (sterilization). While these documents may occasionally stray from science out of an abundance of caution, they are the standards for infection prevention in these settings. Case Study Hospital G: High-level disinfection areas In Hospital G, staff were struggling with the design of the disinfection area. For example, the facility’s door allowed anyone to enter during the decontamination process. As staff worked at the sink, they could see the scopes accumulate for reprocessing, which unconsciously pushed them to work faster, which is a potential problem because working faster at an intricate job can cause mistakes. Physicians were able to enter the decontamination area through the door and urge the staff to rush. In addition, the visibility at the sink was not ideal, and it was difficult to see whether the brushes had debris on them, which could interfere with adequate brushing. The facility aimed to minimize this problem by bringing in a wheeled magnifying glass, but the area was so small that the glass was challenging to use. After decontamination, the scopes were taken across the hall to a room with automated endoscope reprocessors, but carrying the scopes across the hall posed a risk of staff bumping into someone coming out with a clean scope.

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To address these challenges, a new design was created to minimize disruption and provide adequate space and visibility. To accommodate this new design, the reprocessing areas were expanded into other areas, which meant a loss of clinical space and some offices but allowed for proper reprocessing. The facility had to change the ventilation and upgrade these areas to reflect newer code requirements. A locking feature on the door has kept physicians from interrupting the reprocessing procedures and rushing processes. Although the new design cost the facility resources, it has led to improved reprocessing.

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Spaulding, E. H. (1968). Chemical disinfection of medical and surgical materials. In: C. Lawrence, & S. S. Block (Eds.), Disinfection, sterilization, and preservation (pp. 517531). Philadelphia: Lea & Febiger. 305 Favero, M. S., & Bond, W. W. (2001). Chemical disinfection of medical and surgical materials. In: S. S. Block (Ed.), Disinfection, sterilization, and preservation (pp. 881-917). Philadelphia: Lippincott Williams & Wilkins. 306 Association for the Advancement of Medical Instrumentation. (2014). Water for the reprocessing of medical devices (AAMI TIR34). Arlington, VA: AAMI. 307 U.S. Geological Survey. (2016, December). Water Hardness. Retrieved from https://water.usgs.gov/edu/hardness.html (accessed January 17, 2018) 308 U. S. Food and Drug Administration. (2015, August). Supplemental measures to enhance duodenoscope reprocessing [FDA Safety Communication]. Retrieved from FDA http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm454766.htm 309 American National Standards Institute, Association for the Advancement of Medical Instrumentation. (2012). Ethylene oxide sterilization in health care facilities: Safety and effectiveness (ANSI/AAMI ST41:2008/(R)2012). New York: ANSI. 310 Occupational Safety and Health Administration. (2018). Occupational exposure to ethylene oxide (Code of Federal Regulations, Title 29, Part 1910.1047). Washington, D.C.: OSHA. 311 Occupational Safety and Health Administration. (2016). Occupational exposure to formaldehyde (Code of Federal Regulations, Title 29, Part 1910.1048). Washington, D.C.: OSHA. 312 Kirk, B. (2001). Noncondensable gases (NCG) in the steam supply of a sterilizer. Zentral Sterilisation, 9(5), 317–334. 313 American National Standards Institute, Association for the Advancement of Medical Instrumentation. (2017). Comprehensive guide to steam sterilization and sterility assurance in health care facilities (ANSI/AAMI ST79:2017). New York, ANSI. 314 Walker, J. (Ed.). (2014). Decontamination in hospitals and healthcare. Amsterdam, The Netherlands: Woodhead Publishing. 315 Occupational Safety and Health Administration. (2016). Heat Illness Can Be Deadly. Retrieved on March 2017 from https://www.osha.gov/SLTC/heatillness/index.html. 316 Facility Guidelines Institute. (2014). Guidelines for the design and construction of hospitals and outpatient facilities. Chicago: FGI. 317 Facility Guidelines Institute. (2014). Guidelines for the design and construction of hospitals and outpatient facilities. Chicago: FGI. 318 ASHRAE. (2013). Standard 170-2013:Ventilation of Health Care Facilities. Atlanta, GA: ASHRAE. 319 Memarzadeh, F. (2011). The environment of care and healthcare-associated infections An engineering perspective [Monograph]. Chicago: ASHE. 320 Association of periOperative Registered Nurses. (2016). Guidelines for Sterilization. In

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Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. Association for the Advancement of Medical Instrumentation. Management of loaned critical and semi-critical medical devices that require sterilization or high-level disinfection. (AAMI TIR63). Arlington, VA: AAMI. 322 American Institute of Architects Academy of Architecture for Healthcare. (2006). Guidelines for design and construction of hospital and health care facilities. Washington, D.C.: American Institute of Architects Press. 323 Occupational Safety and Health Administration. (ND). Central supply. Retrieved from http://osha.gov/SLTC/etools/hospital/central/central.html. 324 International Association of Healthcare Central Service Materiel Management. (2016). Central service technical manual. 8th ed. Chicago: IAHCSMM. 325 Association for the Advancement of Medical Instrumentation. (2004/2010). Table-top dry heat (heated air) sterilization and sterility assurance in health care facilities (ANSI/AAMI ST40:2004/(R)2010). Arlington, VA: AAMI. 326 Association for the Advancement of Medical Instrumentation. (2010/2014). Table-top steam sterilizers (ANSI/AAMI ST55:2010/(R)2014). Arlington, VA: AAMI. 327 Association for the Advancement of Medical Instrumentation. (2015). Flexible and semi-rigid endoscope processing in health care facilities (ANSI/AAMI ST91:2015): Arlington, VA: AAMI. 328 U.S. Food and Drug Administration. (2016). Information about automated endoscope reprocessors (AERs) and FDA’s evaluation. Retrieved from http://www.fda.gov/medicaldevices/productsandmedicalprocedures/reprocessingofreusa blemedicaldevices/ucm483896.htm# 329 Kovaleva, J. (2017) Endoscope drying and its pitfalls. Journal of Hospital Infection, 97(4). 330 Joint HVAC Taskforce. (2015, September). Joint interim guidance: HVAC in the operating room and sterile processing department. Retrieved from https://www.aorn.org//media/aorn/guidelines/position-statements/posstat-safety-hvac-interim-guidance.pdf. 321

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CHAPTER 4: Cleaning and Disinfection of Environmental Surfaces

Dan Bennett, CHESP, M-TCHEST, Director Environmental Services, St. Joseph’s Hospitals, BayCare Health System Introduction In today’s health care environment, environmental cleaning and disinfecting of surfaces is a critical component in the prevention of healthcare-associated infections. Surfaces form part of the environmental reservoir that are highly susceptible to contamination to many different dangerous pathogens. 331, 332 Three approaches exist for routine disinfection of hard, non-porous surfaces in patient rooms: chemical disinfection with manual cleaning; using “self-disinfecting” surfaces that are impregnated or coated with metals such as copper, silver, and germicides and no-touch technology such as ultra violet light (UV-C) or fogging with hydrogen peroxide vapor or mist. 333 Multiple studies suggest that environmental contamination plays a key role in the transmission many dangerous pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE) and Clostridium difficile. 334, 335 All three of these pathogens survive for prolonged periods of time in the environment, and infections have been associated with surface contamination in hospital rooms and of health care personnel’s hands. 336 Specifically C. difficile requires enhanced cleaning interventions to effectively reduce the presence of C. difficile spores on high-touch environmental surfaces in patient rooms. 337, 338, 339 A patient room where the prior occupant was infected with MRSA, VRE or C. difficile significantly increase the odds of the next patient acquiring one of those bacteria. Healthcareassociated infections represent the most common adverse event in the intensive care unit; ICU rooms have been found to confer a 40 percent increased risk of acquiring MRSA and VRE, presumably, in part, through environmental contamination. 340, 341 By using the best practices and recommendations outlined in this guide, health care leaders can identify environmental process deficiencies, develop an action plan for correcting these deficiencies, implement the action plan and monitor the plan for positive outcomes. For both existing and new facilities, a multidisciplinary team comprised of administration, nursing, environmental services, infection prevention, facility management, materials management and biomedical engineering should be formed for a successful environmental program. Collaboration between the hospital and health system infection prevention and control practitioner and the environmental services professional is paramount to the success of the environmental cleaning and disinfection program. Creating and sustaining a successful cleaning and disinfection program should include several key components using a bundle approach and will require ongoing commitment from health care leaders. Key components of this bundle should include establishment and reporting of metrics to validate environmental cleaning, policies and procedures to delineate cleaning responsibilities among staff, selection of appropriate cleaning products and determination of the application method for the products, and education, monitoring and feedback for the staff. 342

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The multidisciplinary team has many tools and resources at their disposal to help the bundle to be successful, including the Association for the Health Care Environment (AHE) practice guidance for health care environmental cleaning for evidence based-cleaning and disinfecting processes; 343 the APIC’s infection-prevention environmental services competencies and 344 environmental services infection control committee report for environmental services ; the Centers for Disease Control and Prevention toolkit for evaluating environmental cleaning and disinfection checklist 345 and the AHE’s certification for front-line environmental services with the 346 Certified Healthcare Environmental Services Technician program. Pathogens are most commonly transferred via health care personnel’s contaminated hands from one infected patient to a susceptible patient. When the hands of health care personnel come into contact with contaminated room surfaces or medical equipment, frequently the hands and/ or gloves become contaminated. Studies have shown hand contamination with MRSA occurred with the same frequency whether the health care personnel had direct contact with the infected patient or only touched contaminated surfaces. 347 Importantly, C. difficile hand contamination of health care personnel is directly tied with the intensity of the environmental contamination; hand contamination was 0 percent when the environmental contamination was 0 to 25 percent, 8 percent when the environmental contamination was 26 to 50 percent, and 36 percent when the environmental contamination was greater than 50 percent. 348 Multiple studies have shown that environmental surfaces in a room with a patient that is infected with MRSA were contaminated 1 percent to 27 percent of the time and from a few percent to 64 percent of the time in burn units with MRSA patients. 349 Patients colonized with VRE found the frequency of environmental contamination to reach 60 to 70 percent, and patients that used a couch or chair were found to be positive for VRE 36 to 56 percent of the time. 350 For patients in a room infected with C. difficile, the environmental contamination was shown to be widespread with a range of 2.9 to 75 percent contamination. 351 Commonly contaminated surfaces and equipment include bed rails, bedside tables, surfaces of ventilators, sinks, suction equipment, mattresses, resuscitation equipment, curtains, slings for patient lifting, mops, buckets, door handles, stethoscopes, incubators and computer keyboards. 352 Numerous studies have shown that environmental surfaces are often inadequately cleaned when manual cleaning is conducted with chemicals. Researchers marked high-touch surfaces in rooms with a marker visible only under ultraviolet (UV) light to determine whether the surfaces had been cleaned. 353 In one of those studies, 1,404 surfaces in 157 patient rooms were checked after routine cleaning, and only 47 percent of the surfaces had actually been cleaned; 44 percent of the surfaces in the intensive care unit had been cleaned during discharge cleaning. 354, 355 Eliminating environmental surface contamination as a source for patient to patient transmission of pathogens will require multiple interventions, which was illustrated in a recent study that dramatically reduced the frequency of positive surface cultures of C. difficile. 356Interventions to improve surface cleaning and disinfection include improving education of the environmental services team on the cleaning processes, creating a checklist to ensure that all surfaces are cleaned and disinfected and using a method to audit and assess the cleanliness of the environment with immediate feedback to the environmental services team. These interventions have been demonstrated to improve the frequency of adequate cleaning to the range of 71 percent to 77 percent. 357, 358 The number of healthcare-associated infections that may have been prevented by improving the cleanliness of the environmental surfaces in

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hospital rooms is unknown. By understanding how these surfaces can contribute to the possible transmission of these dangerous pathogens, health care leaders can identify which surfaces may become contaminated, assess current practices and enhance disinfecting processes of these surfaces as another strategy for infection prevention. Brief Literature Review Many of the surfaces in the room of an infected patient are contaminated and then serve as a reservoir for microbial growth. Environmental surfaces that are likely to be contaminated by one of these pathogens can be divided into two groups: those frequently touched by hand contact (doorknobs, bedrails, light switches, overbed table, nurse call box, etc.) and those with minimal hand contact (for example, floors, ceilings, walls). The hands of health care personnel come into contact with these high-touch surfaces, and then come in contact with another device or surface, contaminating that as well. Once a surface is contaminated, dangerous healthcareassociated pathogens can survive for prolonged periods of time if no regular surface disinfection is performed. MRSA and VRE can survive for days and months on dry surfaces, while C. difficile (spores) can survive months (Table 2). 359 Table 2: Survival of common healthcare-associated pathogens

Environmental contamination is an important factor in patient-to-patient transmission; data from a number of studies have found that patients admitted to a room in which the prior occupant was infected with a particular pathogen are significantly more likely to acquire that same pathogen during their hospital stay than patients who are admitted to a room in which the prior occupant was not infected. 360, 361, 362 Since the patients had no direct contact, the risk is associated with the environment of the patient room. Overall, the odds of acquiring the organism were more than 1.5 to 2 times higher among patients admitted to the rooms in which the prior occupant was infected with C. difficile, MRSA and VRE. 363, 364, 365 These findings suggest that frequent environmental contamination poses a real risk to the next patients who are admitted to these contaminated rooms. Therefore, proper disinfection of the surfaces and equipment that patients and health care personnel touch frequently is required to reduce exposure in these rooms. Several new technologies have entered the health care market that have the potential to close this gap and enhance the containment of multidrug-resistant organisms. These technologies include improved chemical disinfection, self-disinfecting surfaces and engineered “no touch” automated disinfection systems. 366, 367, 368

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An evaluation of improved chemical disinfection using a new activated hydrogen peroxide wipe disinfectant was used to disinfect 10 high touch surfaces in 72 patient rooms and significantly improved disinfection of the surfaces. 369 The evaluation revealed that after cleaning, 99 percent of surfaces yielded less than 2.5 colony-forming units/cm2, 75 percent yielded no growth and 70 percent yielded adenosine triphosphate (ATP) counts of less than 250 relative light units. Another study showed improved hydrogen peroxide was significantly superior to a standard hydrogen peroxide cleaner at the same concentrate and superior or similar to the quaternary ammonium compound. 370 Self-disinfecting surfaces can be created by coating or impregnating surfaces with heavy metals (for example, copper or silver) and germicides (for example, organosilane compounds). Other miscellaneous methods (for example, light-activated antimicrobials) can be used. Copper ions are lethal to a wide range of pathogens. One study showed that patients cared for in intensive care unit rooms with copper alloy surfaces had a significantly lower rate of incident healthcareassociated infection and/or colonization with MRSA or VRE than patients treated in standard rooms. 371 For the study, patients were randomly placed in available rooms with or without copper alloy surfaces, and the rates of incident healthcare-associated infection and/or colonization with MRSA or VRE in each type of room were compared. The rate of healthcareassociated infection and/or MRSA or VRE colonization in intensive care unit rooms with copper alloy surfaces was significantly lower than that in standard intensive care unit rooms (0.071 vs 0.123; P = .020). For healthcare-associated infections only, the rate was reduced from 0.081 to 0.034 (P = .013). Copper was also found to consistently limit surface bacterial burden before and after cleaning through its continuous antimicrobial activity. 372 Silver has long been recognized for its antimicrobial properties: it has been used to purify drinking water, treat medical conditions and prevent the spread of disease. Research has shown that surfaces constructed of stainless steel with silver-based antimicrobial coatings have the potential to reduce MRSA rates. Copper along with other self-disinfecting surfaces require further studies to determine whether their use reduces healthcare-associated infections. The third group of technologies, “no-touch” automated disinfection systems, has been developed to enhance terminal and discharge room cleaning. These systems commonly use either ultraviolet light or hydrogen peroxide, although there are a variety of systems and chemicals available in automated format. One type of device emits UV light, and another produces a mist or vapor of hydrogen peroxide. Germicidal Ultraviolet light uses UV-C wavelength light, which is germicidal and involves breaking down the molecular bonds in DNA, thereby rendering the organism sterile. Germicidal Ultraviolet light has microbicidal activity against a wide range of pathogens, including C. difficile. Hydrogen peroxide misting is the aerosolizing of dry-mist hydrogen peroxide or vapor to decontaminate a room. Hydrogen peroxide systems have also shown to have microbicidal activity against a wide range of pathogens, including C. difficile. One study was performed to determine the effectiveness of an ultraviolet light-emitting device to eliminate clinically important healthcare-associated pathogens in a contaminated hospital room. 373 The results of the study showed UV-C light reduced the counts of vegetative bacteria on surfaces more than 99.9 percent within 15 minutes, and the reduction in C. difficile spores was 99.8 percent within 50 minutes. A study was conducted to determine whether hydrogen peroxide misting decontamination could reduce environmental contamination. 374 The results showed that 11 of 43 (25.6 percent) cultures of samples collected by sponge from surfaces before hydrogen peroxide misting yielded C. difficile, compared with 0

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of 37 cultures of samples obtained after hydrogen peroxide misting decontamination (P < .001). Another study compared ultraviolet light and hydrogen peroxide misting. The processes were performed in 15 patient rooms; five high-touch sites were sampled before and after the processes and aerobic colony counts were determined. 375 The results showed that ultraviolet light and hydrogen peroxide misting reduce bacterial contamination, including spores, in patient rooms, but hydrogen peroxide misting was significantly more effective. Ultraviolet light was significantly less effective for sites that are out of direct line of sight. Multiple studies have proven the efficacy of these no-touch room decontamination systems and suggest that they may be more reliable in reducing transmission of healthcare-associated infections. These technologies should be considered for use in the health care setting as a supplement and do not replace standard manual cleaning and disinfecting of surfaces. Best Practices and Recommendations The cleanliness and disinfection of the health care environment is important for infection prevention and the patient’s well-being. This effort starts with hospital leaders forming a multidisciplinary team that should include the people with the knowledge and experience to make decisions aimed at improving the cleaning and disinfection of the environment throughout the entire organization. 376The following disciplines should be included on the team: administration, infection prevention and control, nursing, environmental services professionals and facility management. The team’s focus should be on developing and sustaining a successful cleaning and disinfection program. Multiple stages need to be followed to develop a successful program, and sustaining the program will require the ongoing commitment of everyone in the organization. Stage 1 Stage one of the program is determining what chemicals will be used to clean and disinfect the various surfaces in the health care environment. Disinfectants that are to be used in the health care setting must be registered with the Environmental Protection Agency for that use. The environmental services team generally performs intermediate-level disinfection and low-level disinfection functions in a health care facility. 377 The most commonly used chemical disinfectants are quaternary ammonium compounds (referred to as quats) for routine cleaning and disinfection. They are bactericidal, virucidal against enveloped viruses and fungicidal, but not sporicidal and generally not mycobactericidal or effective against nonenveloped viruses. Sodium hypochlorite (commonly known as bleach) is bactericidal, fungicidal, virucidal, mycobactericidal and sporicidal and is generally recommended for surfaces or objects contaminated with C. difficile spores. Accelerated hydrogen peroxide has been recently introduced for surface disinfection with generally short contact times; it is bactericidal, virucidal, fungicidal, sporicidal and mycobactericidal. When selecting products for cleaning and disinfection, many factors must be considered. First, consider the disinfectant’s spectrum of activity (kill claim), in other words, the pathogens against which it has been proven to be effective. For example, quaternary ammonium compounds are often recommended for multiple drug resistant organisms such as MRSA and VRE, while sodium hypochlorite or an Environmental Protection Agency (EPA)-registered sporicidal disinfectant is recommended to kill C. difficile spores. An EPA-registered disinfectant labeled as a tuberculocidal will also be needed. Look for products that have short contact times, a one-step cleaner and disinfectant that is compatible with surfaces, non-corrosive and that has long shelf

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life. Information on these qualities can be found in the manufacturer’s technical data sheets and safety data sheets. Follow the product manufacturer’s recommendations for use on certain surfaces and use the correct dilution ratio. Once the chemical selection is completed and guidelines are set on when to use what chemical for a specific pathogen, a determination will need to be made on how the disinfectant will be applied to the surfaces. The disinfectants can be applied with cotton cloths, microfiber cloths or disposable wipes. The disinfectant may be wiped with a moistened cloth, sprayed or applied with a saturated cloth soaked in a disinfectant filled bucket. The most important factor is that the disinfectant be applied liberally enough to achieve the appropriate wetness to ensure that the disinfectant contact time is achieved per the label’s instructions. A method for achieving the correct chemical dilution will need to be decided; most chemical vendors offer automated dispensing and mixing systems to ensure accurate dilution ratios each time. Other methods include ready to use bottles and ready to use wipes, although there is a substantial additional cost associated with these methods. Stage 2 Stage two of the program is defining policies and procedures, and every discipline that has any role in the cleaning process needs to be represented at this stage so that policies and procedures can be effectively defined. 378 The policies need to clearly define the cleaning task, the responsible department to perform the task, the cleaning frequency and the products to be used. 379 Table 3 is an example of a grid that defines the cleaning task within the policy. 380

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Table 3: Cleaning tasks defined

Using the Spaulding classification, which categorizes levels of disinfection based on the object’s intended use and the risk for infection with the use of that item, noncritical items in the health care setting are those that only touch intact skin, and these require low-level disinfection, and an intermediate-level disinfection for C. difficile. Equipment should be disinfected between patients

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if shared or at least daily and at terminal cleaning. 381 Protocols for cleaning these noncritical items are to be consistent, such as cleaning and disinfecting of all high touch surfaces (bed rails, overbed table, nurse call button etc.). These high touch surfaces that frequently come in contact with the hands of patients or health care personnel should be cleaned and disinfected daily (or more frequently) and at terminal cleaning. Identify which areas might call for less frequent cleaning because they are not likely sources of contamination (walls, ceilings, window sills); these noncritical surfaces need cleaning only when visibly soiled and periodically. Outline the steps employed for cleaning occupied patient rooms and terminal cleaning of patient or procedure rooms. 382 When defining cleaning and disinfection protocols, follow predetermined guidelines for the cleaning path (top to bottom, clockwise/counterclockwise, clean to dirty); this will ensure that no areas are skipped and help prevent pathogens from being transferred from a dirty area to a clean area. 383 The restroom in the patient room should always be cleaned last to reduce the 384 385 386 387 388 To likelihood of spreading contaminants and to increase efficiency and safety. , , , , maintain quality and consistency among environmental technicians, the environmental services professional should predetermine the logical cleaning path to be followed. 389 Figure 6 is an 390 example of a predetermined cleaning path for a semi-private room. Figure 6: Cleaning path for semi-private room

When it comes to assigning responsibility for cleaning equipment, environmental services, nursing and infection control should collaborate to decide who is going to clean and disinfect specific non-critical equipment. Examples of non-critical equipment to consider may include infusion pumps, sequential compression device pumps, glucometers, blood pressure monitors, mobile computers or workstations and handheld tablets or smartphones (and the cleanable protective cases that often accompany such equipment). Once all parties agree on who will be responsible for cleaning each type equipment, compile a list. The list should have the following outlined on it: the equipment name, the standard of cleaning (for example, after use or when visibly soiled), method of cleaning and type of disinfectant, the group responsible for cleaning

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and any additional comments. The standard of cleaning should be determined by the infection control committee, while the method of cleaning should be determined by the manufacturer’s instructions and, at a minimum, non-critical equipment should be disinfected when visibly soiled, prior to use on a patient and on a regular basis. Incorporate this list of responsibilities into new hire orientation and training for environmental service technicians and staff to prevent confusion about who is responsible for cleaning specific equipment. Checklists and daily assignment sheets should be developed that will help the environmental services technicians properly complete the tasks that they are performing. Checklists are a useful tool to standardize the daily cleaning and disinfecting practices and encourage the technician to adhere to the cleaning process. The cleaning checklist should include low- or intermediate-level disinfectants specific to the type of isolation the technician may encounter. The daily assignment sheet should have all areas listed for that assignment and have the amount of time the technician has to complete the cleaning in each area. The time for completing each area should be sufficient to allow a thorough cleaning, accounting for adequate contact time for cleaning agents. Checklists and daily assignment sheets can be easily implemented. Figure 7 is an example of a daily assignment sheet.

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Figure 7: Sample daily assignment sheet

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When performing cleaning for an isolation room, follow the same procedures as used for a regular room cleaning. In addition, a few more detailed steps will be included. Don appropriate personal protective equipment for the particular isolation precaution following the isolation sign 391 instructions and check for proper fit before entering the room. Use the specified disinfectant for the type of isolation—for example, quaternary ammonium compounds are often recommended for multidrug-resistant organisms such as MRSA and VRE, while sodium hypochlorite or an EPA-registered sporicidal disinfectant is recommended to kill C. difficile spores. Other types may require an EPA-registered disinfectant labeled as a tuberculocidal. 392 These special procedures should be included in the cleaning and disinfection protocols as they relate to isolation cleaning: use low- or intermediate-level disinfectants that are specific to the type of isolation, consider potential contamination of items that need to be cleaned, only leave the room when cleaning is completed, adhere to proper removal protocols of personal protective equipment as it is critical to avoid contamination and exposure to the pathogens, avoid touching the outside of items where infectious organisms may have settled, immediately perform hand hygiene and disinfect cleaning equipment before returning it to the cart. 393 Specifically, when performing cleaning and disinfection of C. difficile isolation, enhanced cleaning strategies should be considered. Studies have shown that using a germicidal bleach wipe and conducting cleaning and disinfection education with the environmental services staff improved the decontamination of surfaces in the room. 394 Another study evaluated additional bleach cleaning in two intensive care units following an increase in patients with C. difficile. The extra cleaning was delivered to all parts of one intensive care unit, including rooms used only by staff. Clinical equipment was cleaned with hypochlorite-containing cloths twice a day. The second unit introduced enhanced bleach cleaning in isolation rooms accommodating patients already infected with C. difficile. Both units witnessed a decrease in infection rates over the next few months, which remained at a lower level for at least two years after the bleach cleaning program. 395 Another study evaluated daily cleaning with germicidal bleach wipes on wards with a high incidence of hospital-acquired C. difficile infection. The intervention was associated with a reduction in hospital-acquired C. difficile incidence by 85 percent, from 24.2 to 3.6 cases per 10,000 patient-days, and prolonged the median time between hospital-acquired C. difficile cases from 8 to 80 days. 396 As shown in the studies, the use of bleach wipes and increased cleaning frequencies may be associated with a decrease in the rates of C. difficile infections in the hospital and should be considered when defining the specific cleaning and disinfection protocols for C. difficile. Stage 3 The next stage, or stage three of the program, is environmental cleaning education for the environmental staff and any other health care personnel designated to clean certain equipment. Ensuring competence of environmental services staff and those assigned to clean equipment is critical and a hospital should have a competency-based training program in place. The Centers for Disease Control and Prevention recommends “structured education,” where the training includes the technician’s role in improving patient safety. 397, 398, 399, 400, 401, 402 The program should reinforce the importance of cleaning and disinfecting and be specific about the expectations and the necessary skills. The environmental team and those assigned to clean equipment must understand the “why” behind their everyday actions and the key role

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environmental services technicians and those that clean equipment play in preventing the spread of infection. 403 Environmental services technicians must be given an abundance of information to perform their daily tasks effectively. They must be educated on the types of pathogens and understand how infection is spread and how they can prevent that spread. They need education on the proper cleaning and disinfecting practices of the required items they are to clean, the frequency of cleaning of those specific items, the guidelines about the order in which to clean those items, the right cleaning/disinfection chemical to be used for the organism, the proper dilution ratio of the products they are using and the correct dwell time to achieve disinfection of the surface they are cleaning. 404 New hire training should include classroom training that covers department policies and procedures, and should include a knowledge assessment, like a written quiz. Training should define how the quality and consistency of their work will be monitored and audited on both a daily and yearly basis. Once classroom training is complete, new hires should train with a preceptor for five to seven days. Once preceptor training is completed, a direct observation assessment should be conducted by environmental services management or the infection control professional at the facility. The assessor should ensure new hires follow environmental cleaning procedures, donning and doffing of personal protective equipment, daily room cleaning, a standard discharge room cleaning and a C. difficile discharge isolation cleaning. New hires should perform two discharge cleanings on their own and have an assessment done once completed. One approach to assessing competency is to have the technician pass an ATP assessment. After environmental services management conducts the assessment, the new hire can work an assignment on their own or if necessary go back for more training based on the assessment outcome. Ongoing monitoring of cleaning should be used for retraining purposes and should not be done as a punitive measure. In addition to new hire training, ongoing training should be provided to maintain competency of existing environmental services staff and those health care personnel assigned to clean equipment. This training should be held monthly, include written exams and attendance should be tracked by management. The training program should include yearly competencies to measure the technicians’ and health care personnel’s technical skill as it relates to cleaning and disinfecting. Achieving a professional certification is one way for environmental services staff to demonstrate expertise. The Association for the Healthcare Environment offers the Certificate of Mastery in Infection Prevention for Environmental Services Professionals; this robust certificate program provides the requisite knowledge for a “trained” professional in infection prevention and control specific to the clinical environment of care. The AHE offers the only certification for front-line technicians that validates their knowledge and technical skills. 405 The Certified Healthcare Environmental Services Technician designation sets national standards specifically for environmental services technicians working in health care. Table 4 is an example of some training and assessment guidelines that environmental services management can follow. Table 5 is a sample of infection control competencies for 406 environmental services.

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Table 4: Sample training and assessment guidelines

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Table 5: Sample infection and control competencies for environmental services personnel

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Table 5: Sample infection and control competencies for environmental services personnel (continued)

Stage 4 Next the multidisciplinary team will need to determine how the environmental cleaning will be audited and monitored. The Centers for Disease Control (CDC), Association for Professionals in Infection Control and Epidemiology (APIC) and other professional associations recommend that health systems monitor their cleaning to ensure the adequacy of their cleaning practices. 407 Four current methods available to monitor cleaning practices include direct observation, aerobic colony counts (contact plates, swab/wipe-rinse, etc.), fluorescent marker systems and ATP bioluminescence assays. Visual assessment after a room has been cleaned can only assess visible cleanliness such as removal of organic debris and dust, not the microbial contamination. Visual assessment alone is not adequate, and another method for measuring surface cleaning

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needs to be selected. 408 Direct observation is the covert monitoring of disinfection cleaning of the individual environmental services staff or those health care personnel assigned to clean equipment and provides an assessment of the individual technician’s adherence to cleaning processes, establishes variations in amount of time spent cleaning and determines if the environmental staff are allowing disinfectants to remain wet on the surfaces for the appropriate dwell time. 409 Aerobic colony counts require the use of a microbiology laboratory, which can be costly and may involve sending counts to a commercial laboratory if the clinical lab is not equipped to test environmental samples. Fluorescent marker systems can be used in a powder or gel form to mark high-touch surfaces before room cleaning and disinfection. The gel form is the most commonly used because it dries to a transparent finish on surfaces, is not easily disturbed and is abrasion resistant. The gel is applied as a dot to the surface and if cleaning is adequate no fluorescence is detected when the dotted surface is exposed to black light, but the fluorescence dot will appear if not cleaned properly. The gel is designed to show the physical removal (wiping of the surface) of an applied substance but does not determine if the surface was disinfected. Advantages to the florescent surface markers include the ease of implementation and low cost when used as a feedback tool for environmental services staff. ATP bioluminescence assays detect the presence of organic debris on a surface. A specific swab is used to sample the surface and placed into luminometer with the results defined in relative light units (RLU). Some studies have shown that certain disinfectants can interfere with the ATP readings. 410 ATP monitoring is commonly used as tool to monitor environmental cleanliness because it is easy to use and can provide direct, rapid feedback for on-the-spot education to environmental services technicians. ATP monitoring systems also have software to help environmental services managers analyze trends and generate reports. Direct observation, the florescent marker system and ATP are monitoring methods that are relatively easy and cost effective to implement within the health system. The team will need to make careful consideration of the advantages and limitations of the cleaning monitoring approaches prior to deciding which system or combination of systems best meets the needs. 411, 412 In 2010 the CDC put out a checklist with recommended surfaces to monitor after 413 terminal cleaning as shown in Table 6.

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Table 6: CDC environmental checklist for monitoring terminal cleaning

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Stage 5 Next in the program, or stage five, is feedback to the environmental services team and those assigned to clean other equipment. Providing feedback is extremely important in the success of the environment cleaning program and has been shown to improve cleaning and disinfection practices. The CDC recommends discussing the results of the monitoring programs and interventions as a “standing agenda item for the Infection Control Committee.” Feedback of the results of the monitoring program should be shared with the environmental services team, unit level leadership, and hospital administration. One study demonstrated significant improvement after feedback was provided to environmental services regarding the results using the fluorescent marker system, before and after study, in 36 acute care hospitals. Fourteen types of objects were included; of the 20,646 standardized environmental surfaces only 9,910 (48 percent) were cleaned at baseline. After structured educational and procedural interventions and objective performance feedback to the environmental services staff, an improvement of 7,287 (77 percent) of 9,464 standardized environmental surfaces were cleaned (P50 years, 300 CFU/100 ml from the heater-cooler unit water maintained as per instructions for use, the final method for decontaminating the heater-cooler units included first replacing the biofilm-coated internal tubing (one completely plugged by biofilm, creating a dead leg), followed by daily addition of medical grade 3 percent (100 ml) hydrogen peroxide to the filtered water and weekly peracetic acid treatment. The final disinfecting regime demonstrated a reduction of recovered pathogens 0 CFU/100 ml. Although the infected case counts attributed to nontuberculous mycobacteria associated with heater-cooler units are small (